CLINICAL
Role of the nurse prescriber
Jenny Stewart
Colorectal Nurse Practitioner,
Nottingham University
Hospitals, Queens Medical
Centre Campus, Department
of Colorectal Surgery
Email: jenny.stewart@nuh.
nhs.uk
ABSTRACT
In December 2005 a team of colorectal clinicians from across Europe met
with the aim of developing an evidence-based treatment algorithm for anal
fissure, to be used in both primary and secondary care. In this article, Jenny
Stewart explores its implications for the management of anal fissure by
nurses in primary and secondary care.
454
in managing anal fissure
A nal fissure is a common, benign condition
that often affects young, otherwise healthy
adults (Jonas et al, 2002). They are characterised
by pain on defecation and anal bleeding (Porrett
et al, 2003; Lund et al, 2006). A fissure is a split
in the lower part of the anal canal extending from
the anal verge towards the dentate line. Most fis-
sures are posterior, but anterior fissures are also
seen in women.
The cause of a fissure is not always clear, but a
fissure often starts following a bout of either con-
stipation or diarrhoea (Jones, 1999). Some heal
spontaneously but many become chronic, causing
months of misery for the patient. A fissure is usually
considered to be acute if it has been present for less
than 6 weeks, and chronic if present for more than 6
weeks (Prodigy, 2006).
Approximately 87% of chronic sufferers are
between 20 and 60 years old. In approximately
10% of cases the fissure occurs during childbirth
(Prodigy, 2006).
Symptoms
Typically patients present with rectal bleeding, which
they often believe to be caused by haemorrhoids,
or severe pain on defecation. It has regularly been
described by patients as 'like passing glass'. There
is also an associated burning pain that may linger
for several hours after defecation in some patients
(Lund et al, 2006). These symptoms significantly
impair quality of life. Successful treatment of anal
fissure means improvement of quality of life (Griffin
et al, 2002; Hyman, 2004) Patients with fissures gen-
erally have internal anal sphincter tightness leading
to raised resting canal pressure and anal spasm
(Lund and Scholefield, 1997; Jonas et al, 2002)
and treatment shou d be directed at reducing these
factors (Jonas et al , 2002). Internal anal sphincter
activity and resting anal pressure can be reduced
with either surgicai or pharmacological treatments
(Bielecki and Kolodziejczack, 2002).
Medical management of anal
fissure
Before the algorithm, treatment for anal fissure
varied from clinician to clinician and many treat-
ment centres followed guidelines based on local
experience (Lund et al, 2006) Treatment for anal fis-
sure was dependent on which clinician trained the
colorectal nurse practitioner. Without any clear
guidelines this could not improve.
Some doctors in primary care are highly compe-
tent in fissure diagriosis and management, whereas
others are not so confident. However, the publication
of this treatment algorithm now provides evidence-
based guidance to help health care professionals
decide on the most appropriate treatment.
Algorithm
The development o' the European algorithm for anal
fissure managemerit has benefits for all concerned.
Most importantly the patients can receive fast relief
of their symptoms^ as it allows them to receive
first line treatment within primary care. It can also
delay or stop the rieed for a referral to secondary
care. Often referrals into secondary care can take
many weeks and during this time a patient can be
in severe pain. Haying an algorithm gives primary
care doctors and nurses the knowledge to optimally
treat anal fissures n the best way possible, which
in turn will reduce the pressure and waiting times in
secondary care.
Treatment options
On presentation, the patient is assessed and a
full history is taker|. On diagnosis of anal fissure a
medication can be prescribed as first-line treatment
to heal the fissure.
Niiijrse Prescribing, 2006/2007 Vol 4 No 11
 Table 1
Causes and symptoms of an anal fissure (Porrett et al,
2003; Lund et ai, 2006)
Causes
• Habitual use of laxatives
• Constipation
• Diarrhoea
• Injury to anal canal during labour
Symptoms
• Sudden, severe pain in and around anus, ofen occurring during, or shortly after, bowel movement
• Streak of blood on toilet paper
• 'Sentinel pile': a small tag of skin that develops on the edge of the anus where the fissure lies
Glyceryl trinitrate ointment
Glyceryl trinitrate (GTN) ointment has been used to
produce a chemical sphincterotomy with varied heal-
ing rates of up to 86% in some studies (DasGupta et
al, 2002; Lund et al, 2006). In the recent Cochrane
review GTN was found to be significantly better than
placebo in healing fissures (Nelson, 2006). However,
up to 80% of patients develop headaches during
treatment and this can lead to poor compliance
(DasGupta et al, 2002). Although the concentration
of GTN has not been found to affect outcomes,
education of how to use it does (Brown et al, 2001).
It should be used 2-3 times daily for 6-8 weeks to
improve outcomes. Nurses should inform patients
of the side-effects, and that they do improve with
time to help promote compliance (Nelson, 2006).
The headaches experienced are temporary and relief
from these headaches can be achieved with simple
oral analgesia (Lund et al, 2006).
Calcium channel blockers
Diltiazem, a calcium channel blocker, has been
evaluated as an alternative treatment to GTN with
up to 75% healing rates observed (Brown et al,
2001). In the Cochrane review there was insuf-
ficient evidence to conclude the effectiveness of
diltiazem but several studies have found that it is
equally effective in healing anal fissure compared
with GTN (Bielecki and Kolodziejczak, 2002); this is
though to result from increased compliance as fewer
side-effects occur.
Until recently the topical treatments for anal
Nurse Prescribing, 2006/2007 Vol 4 No 11
fissure were unlicensed for that use. Both diltiazam
and GTN 0.2% had to be prepared at the request
of doctors and could only be prescribed within
secondary care. Diltiazam is still unlicensed for use
but Rectogesic (GTN 0.4%) was launched in June
2005 in the UK and was the first licensed topical
treatment for the pain management of chronic anal
fissure. Unlike GTN 0.2%, Rectogesic is a standard
unit dose and therefore provides consistent qual-
ity, supply and dose. The most common adverse
event was dose-related headache which occurred
with an incidence of 50% (Rectogesic Summary of
Product Characteristics, 2005). It can be prescribed
in both primary and secondary care and can also be
prescribed by nurse prescribers as well as by our
medical colleagues. This makes it easier and quicker
for patients to obtain treatment and, therefore, relief
of symptoms.
According to the treatment algorithm, if the fissure
remains unhealed after 6-8 weeks, patients should
be referred to secondary care for consideration of
further pharmacological treatment or surgery.
Surgery
Evidence has suggested that surgical sphincterotomy
is an excellent treatment for chronic anal fissure as
it relieves the symptoms and has a low recurrence
rate (Brown et al, 2001; Richard et al, 2002). Surgery
can lead to rapid healing in 90-95% of patients
(Lund et al, 2006). However, there is an increased
risk of anal incontinence from surgery, with the inci-
dence ranging from 8% to 39% (Brown et al, 2001;
455
 CLINICAL

Primary care management of chronic anal fissure

Adapted from and approved by: Lund JN et al. An evidence-based treatment algorithm tor anal issune. Tech Coloproctol 2006;
10: 176-179. Reproduced vwith permission from Springer ©.

lion A
Patient history and external examination

Also recurrent Idiopathic anal fissure

uncomplicated (first presentation, no history of
anal fissures Crohn's disease, HIV infection, etc)

First-line treatment*:
Licensed: topical GTN 0.4%, Analgesics (local >
Unlicensed: GTN 0.2%, ISDN, calcium channel blocker inn
bulking »»»»- anaesthetic, NSAiDs)
agents and dietary modifications ^ if pain extreme

Healed:
z \
6-8 weeks 6-8 weeks

X
Unhealed and
irid
;ic or
asymptomatic
\
\
V discharge I Unhealedand \ sment I
some improvement
\ I V symptomatic |

Second 6-8 week

course of topical

L Refer to

secondary care
\

]
therapy

Unhealed: refer to
secondary care

"according to licensing availability, costs and contraindications

GTN - glyoeryl trinitrate; ISDN - isosorbide dinitrate; NSAIDs - non-steroidal anti-inflammatoty drugs

Nelson, 2006). It is because of these risks that
alternatives to surgery, such as topical GTN, were
sought to reduce the anal canal pressure and
spasm.
Nursing management of anal
fissure
It is now accepted that many areas of treatment
for common coloproctological conditions can be
managed by a suitably trained nurse practitioner
(Porrett, 1996; Porrett et al, 2003; Lewis et al,
2004; Fitzgerald-Smith et ai, 2005). In 2002 Porrett
et al published a study looking specifically at the
management of anal fissure by nurses. The authors
concluded that patients respond more positively
to a nurse practitioner compared with a doctor, as
nurses were able to offer more time for discussion,
information giving and education.
In terms of management, treating the cause is a
good piace to start. This involves encouraging the
patient to increase fibre intake often using a bulk
laxative, and ensuring a high fiuid intake to make a
soft stool (Brown et al, 2001; Lund et al, 2006).
These methods, along with a nurse-led education
can be effective in relieving anal fissure and should
always be considered along with other treatments of
fissure (Porrett and Lumiss, 2001; Porrett et al, 2003;
Lund et al, 2006).
Nurse prescribing for anal fissure
Before May 2006, :he British National Formulary
(BNF) nurse prescriDers' extended formulary was
very limited. Independent prescribers couid only
prescribe from a set list of conditions and from a
iimited number of medications. The only condition
a nurse prescriber couid independently prescribe
for was constipatiori, from within the gastro-intes-
tinal conditions (BNF, 2006). Specifically, with the
management of anal fissure in mind, this would
allow the prescription of a buik-forming laxative
but neither of the topical treatments for anal fissure
I
(GTN or diltiazem). Under supplementary prescrib-
ing any drug could be prescribed, but within the
colorectal clinic the jse of supplementary prescrib-
ing has iimited effeci iveness as the doctor agreeing
to the supplementary plan had to diagnose the

456 Nurse Prescribing, 2006/2007, Vol 4 No 11

condition. Traditionally, the use of nurses within
these clinics came from the need for them to see
newly referred patients, thus ruling out the use
of supplementary prescribing (Lewis et al, 2003;
Fitzgerald-Smith et al, 2005).
Although anal fissures can be chronic in nature,
patients with them are rarely seen in the outpatient
clinic on more than three occasions. This was a
limiting factor on the usefulness of supplementary
prescribing in this setting. It may be that there are
not many nurse prescribers who specialise within
the area of colorectal. To obtain a prescription for
GTN or diltiazam in the past required a good working
and trusting professional relationship with a medical
colleague who would prescribe treatment based on
the nurse's diagnosis.
The opening of the BNF in May 2006 has enabled
more nurses from more varied clinical backgrounds,
including colorectal, to become independent nurse
prescribers. We can now prescribe any licensed
medicine within our clinical competence and may
even prescribe medicines outside of their licensed
indication. However we must accept profession-
al, clinical and legal responsibility (Department of
Health, 2006). This allows full nursing management
of anal fissure. The treatment algorithm recommends
that first line treatment should be based on licensing,
availability, costs and contraindications. Currently,
Rectogesic is the only licensed treatment for anal
fissure pain - diltiazem currently remains unlicensed
for anal fissure pain based on the available evidence
(Brown et al, 2001; Bielecki and Kolodziejczak, 2002;
DasGupta et al, 2002). Therefore, if we prescribe a
product which is not licensed for anal fissure pain,
we must accept the professional, clinical and legal
responsibility, although we have the algorithm on
which to base our prescribing decision.
Nurses who work in primary care have the same
rights to prescribe as a colorectal nurse in secondary
care and therefore could use the algorithm. However,
there is currently no literature available on nurse-
led anal fissure management within primary care.
One published study looks at nurse-led colorectal
intervention within primary care. It concluded that
primary care can provide a service with extended
nursing roles but that extensive training and support
from secondary care is needed for this to be truly
successful (Maruthachalam et al, 2006). This would
seem to indicate that the majority of colorectal
nurses who manage, diagnose and prescribe are in
secondary care.
Conclusion
The future of anal fissure management has poten-
Nurse Prescribing, 2006/2007, Vol 4 No 11
Table 2
Advice to help patients manage chronic anai
fissure (Prodigy, 2006)
Lifestyle advice
Constipation can be helped by:
• High-fibre diet with plenty of fluids
• Fibre supplements
• Bulk forming laxatives
Dealing with the discomfort
• Warm baths
• Anaesthetic creams or ointments
• Hydrocortlsone
• Lubricants
• Good toilet hygiene
• Analgesics, such as paracetamol
tially been changed by the publication of these
guidelines. It has enabled primary care teams to
initiate first-line treatment by providing them with an
evidence-base to make their decisions. If successful
and adopted by primary care the number of referrals
to secondary care will be reduced which can only
be beneficial for all involved, especially the patient
who will be able to receive immediate treatment and
hopefully relief of their symptoms. Currently, it would
seem that the nursing management and prescribing
for colorectal conditions is focused mainly in sec-
ondary care. In the future it may be that primary care
nurses receive training to manage simple colorectal
conditions and this algorithm will strengthen the
possibility of this happening. Although this algorithm
seems to transfer responsibility of anal fissure to
the primary care team what it actually aims to do is
rationalise the treatment of anal fissure in primary
and secondary care settings (Lund et al, 2006). It
may even improve the relationships and team work-
ing between primary and secondary care as a whole,
which would only benefit the patient if successful. «a
Bieiecki K, Kolodziejczak M (2002) A prospective randomized
trial of diltiazem and glyceryltrinitrate ointment in the
treatment of chronic anal fissure. Colorectal Dis 5:
256-257
British National Formulary (2006) BMJ Publishing, London
Brown SR, Taylor A, Adam IJ, Shorthouse AJ (2001) The
457
 CLINICAL

KEY POINTS
•Anal fissure Is a common, benign condition that affects otherwise healthy adults. It is a split in the
lower part of the anal canal extending from the anal verge towards the dentate line.
• A fissure often starts following a bout of constipation or diarrhoea. In approximately 10% of cases the
fissure occurs during childbirth.
•Typically patients present with rectal bleeding or severe pain on defecation.
•Medical treatment options include calcium channel blockers, such as diltiiazem and glyceryl trinitrate.
• I n 2005, a European team of colorectal clinicians met with the aim of developing an evidence-based
treatment algorithm for anal fissure to be used in both primary and secondary care.
•The treatment algorithm recommends that first-line treatment shold be based on licensing availability,
costs and contraindications.
•The publication of these guideiines has enabled primary care teams to initiate first-line treatment by
providing them with an evidence base on which to make their decisions.

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Is soya contraindicated in those

taking thyroxine?
See Questions and Answers
I page 459

458 Nurse Prescribing, 2006/2007 Voi 4 No 11