Anal fistula, fissure and haemorrhoids
Key points
Anal fissure
Not necessarily linked to hard stool - ischaemia, anal sphincter hypertonicity, trauma
6-24 months most common presenting age
Consider non-accidental injury
Laxatives (Movicol) should be first line
No additional benefit for introducing calcium channel blocker - Alshehri et al, JPS 2020 RCT
EMLA and GTN are better than placebo and topical lidocaine - Sönmez et al, JPS 2002 RCT
Other options:
Botox
Sphincterotomy, Fissurectomy should only be used as a last resort
Haemorrhoids
Simple anal venous congestion is often mistaken for haemorrhoids
True haemorrhoids rare in children - dilation of submucosal veins
Internal - begin above dentate - will be at 3, 7, 11 o'clock
External - from inferior haemorrhoidal plexus - painful
Management
Laxatives
Decrease time on toilet
Avoid straining (use 'Squatty potty')
Surgery rarely required in children
If conservative management fails - Try banding first
Excision - same technique as rectal strip biopsy
Anal fistula and abscess
In infants
Male > Female
Infection of deep anal crypts - possibly under influence of androgens
Often resolve with no intervention (87% after mean 5 months)
If not resolving - book for EUA + fistulotomy
In older children - examine for Crohns and get MRI if suspected
Use non-cutting Seton suture if Crohns, otherwise should lay open fistula
Goodsall's rule - sinuses opening posterior to a coronal plane in the anus will always open in the midline anal canal. Those opening anterior will take a straight course into the canal. This rule is frequently disputed
Page edited by Mrs Charnjit Seehra BSc November 2024
References
Alshehri A, Barghouthi R, Albanyan S, Alayed M, Alsubaie H, Alhayyan R, Alzahem A, Altokhais T, Albassam A, Aljazaeri A. A prospective, double-blind, randomized, placebo-controlled trial comparing the efficacy of polyethylene glycol versus polyethylene glycol combined with topical diltiazem for treating anal fissure in children. J Pediatr Surg. 2020 Oct;55(10):2017-2021. doi: 10.1016/j.jpedsurg.2020.01.010. Epub 2020 Jan 30. PMID: 32057442.
Sönmez K, Demiroğullari B, Ekingen G, Türkyilmaz Z, Karabulut R, Başaklar AC, Kale N. Randomized, placebo-controlled treatment of anal fissure by lidocaine, EMLA, and GTN in children. J Pediatr Surg. 2002 Sep;37(9):1313-6. doi: 10.1053/jpsu.2002.34997. PMID: 12194122.
Flageole, Helene, et al. "Hemorrhoids." Pediatric Surgery NaT, American Pediatric Surgical Association, 2020. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829531/all/Hemorrhoids.
Flageole, Helene, et al. "Perianal Abscess and Fistula." Pediatric Surgery NaT, American Pediatric Surgical Association, 2020. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829530/all/Perianal_Abscess_and_Fistula.
Cirocco WC, Reilly JC. It is time to retire Goodsall's Rule: the Midline Rule is a more accurate predictor of the true and natural course of anal fistulas. Tech Coloproctol. 2020 Apr;24(4):317-321. doi: 10.1007/s10151-020-02167-z. Epub 2020 Feb 27. PMID: 32107684.