Anal Fissures


Article Author:
Brian Jahnny


Article Editor:
John Ashurst


Editors In Chief:
Evelyn Metz
Julie Sewell
Aditya Arya


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
11/22/2018 8:22:06 PM

Introduction

An anal fissure is a superficial tear in the skin distal to the dentate line and is a cause of frequent emergency room visits. In most cases, anal fissures are a result of hard stools and/or constipation, as well as injury. Anal fissures are common in both adults and children, and those with a history of constipation tend to have more frequent episodes of this condition. Anal fissures can be acute (lasting less than 6 weeks) or chronic (more than 6 weeks). The majority of anal fissures are considered primary/typical occurring at the posterior midline. A small percentage of these may occur at the anterior midline. Other locations (atypical/secondary fissures) can be caused by other underlying conditions that require further workup. The diagnosis of anal fissure is primarily clinical. Several treatment options exist, including medical management and surgical options. [1][2][3]

Etiology

Causes of anal fissures commonly include constipation, chronic diarrhea, sexually transmitted diseases, tuberculosis, inflammatory bowel disease, HIV, anal cancer, childbearing, prior anal surgery, and/or anal sexual intercourse. The majority of acute anal fissures is thought to be due to the passage of hard stools, sexually transmitted infection (STI), or anal injury due to penetration. Chronic anal fissure typically is a recurrence of an acute anal fissure and is thought to be also caused by the passage of hard stools against an elevated anal sphincter tone pressure, with symptoms lasting greater than 6 weeks. Underlying conditions such as inflammatory bowel disease, tuberculosis, HIV, anal cancer, and/or prior anal surgery are predisposing factors to both acute and chronic atypical anal fissures. Approximately 40% of patients who present with acute anal fissures progress to having chronic anal fissures.[4][5]

Epidemiology

Anal fissures present in any age group; however, they are mostly identified in the pediatric and middle-aged population. Gender is equally affected, and approximately 250,000 new cases are diagnosed each year in the United States.[6]

Pathophysiology

The anoderm refers to the epithelial component of the anal canal. The location is inferior to the dentate line. It is a very sensitive area to microtrauma and can form a tear with repetitive trauma or increased pressure. Due to the high pressures in this area, it can result in a delayed healing secondary to ischemia. The tear sometimes can be deep enough to expose the sphincter muscle. Together with spasms of the sphincter, this creates severe pain with bowel movements, as well as some rectal bleeding. It is well known that the most common location of anal fissure is the posterior midline because this location receives less than half of perfusion in comparison to the rest of the anal canal. The perfusion of the anal canal has an inverse relationship to sphincter pressure. Other locations of anal fissures, such as lateral fissure are indicative of an underlying etiology (HIV, tuberculosis, Crohn's, ulcerative colitis, among others). The cause of this other location is not well known. Anterior fissures are rare and are associated with external sphincter injury and dysfunction.

History and Physical

Patients with acute anal fissures present with complaints of anal pain that is worse during defecation. At times, there is associated bleeding with bowel movements but usually not frank hemorrhage. Pain usually persists for hours after defecation. Often, acute anal fissures may be misdiagnosed as external or internal hemorrhoids. Therefore, a thorough physical exam should be performed to delineate between the two. Patients with chronic anal fissures will have a history of painful defecation with or without rectal bleeding that has been ongoing for several months to possibly years. Associated constipation is the most common factor involving chronic anal fissures and patients will provide a longstanding history of hard stools. Patients with underlying granulomatous diseases such as Crohn's disease, among others, will sometimes provide a history of chronic anal pain during defecation that is intermittent rather than constant over an extended period.

The physical exam of the patient with an anal fissure should involve the most comfortable position for the patient. Literature suggests the best position is the prone jackknife position where the patient lies prone and the bed is folded so that the patient is flexed at the hips. The bed typically used to achieve this position is usually in an operating room or procedure room. Therefore, the best way to achieve this position in the acute care or office setting would be to have the patient bend over the exam table. Many times, however, an adequate physical exam can be achieved by having the patient in a lateral decubitus position. It is imperative that physical manipulation of the anus or rectum via digital exam should be kept to a minimum, and instrumentation such as anoscopy should never be used.

In the acute presentation, an anal fissure will appear as a superficial laceration, usually longitudinal extending proximally. Bleeding may or may not be present. The fissure and sometimes the entire anal sphincter may be extremely tender to palpation. In thin patients, this laceration is usually easily identified, however, in the obese patient it may not be as identifiable. In an obese patient, gently pressing on the anterior or posterior anal sphincter may reproduce the pain and a diagnosis can be made.

In the chronic anal fissure, there may be a tear large and deep enough to expose the muscular fibers of the anal sphincter. In addition, due to the repeated injury and healing cycle, the edges sometimes appear raised, and thickening of tissue at the distal ends of the tears may be present, which is called a sentinel pile. Granulation tissue may or may not be present depending on the chronicity and the stage of healing.

Evaluation

If the patient has chronic recurrent anal fissures, an examination under anesthesia is recommended to help diagnose the exact cause and sometimes treat the patient. Evaluation of both acute and chronic anal fissure initially involves determining if it is a primary or secondary anal fissure. As described earlier, a primary or typical anal fissure occurs in the posterior or anterior midline, and an atypical or secondary anal fissure occurs in any location other than a primary anal fissure. If an atypical or secondary anal fissure is encountered, conditions such as Crohn's disease should be immediately ruled out. It is to be noted that patients with Crohn's and/or other underlying conditions can have anal fissures located at the typical/primary locations.

Treatment / Management

Initial treatment of anal fissures is medical. Frequent Sitz baths, analgesics, stool softeners, and a high-fiber diet are recommended. Prevention of recurrence is the primary goal. Adequate fluid intake is also helpful in preventing the recurrence of anal fissures and is strongly encouraged. If conservative management with dietary changes and laxatives fail, other options can be used which include topical analgesics such as 2% lidocaine jelly, topical nifedipine, topical nitroglycerin, or a combination of topical nifedipine and lidocaine compounded by a pharmacy. Topical nifedipine works by reducing anal sphincter tone, which promotes blood flow and faster healing. Topical nitroglycerin acts as a vasodilator to encourage increased blood flow to the area of the fissure, increasing the rate of healing. While both have been shown to be effective treatments, topical nifedipine is regarded to be superior to topical nitroglycerin in 2 ways. First, nifedipine has been found to result in a higher healing rate compared to nitroglycerin. Second, it resulted in fewer side effects as nitroglycerin frequently causes headaches and hypotension. If patients use nitroglycerin, it is recommended that they apply the ointment in a seated position and refrain from standing too quickly. Patients should also be advised to avoid medications such as sildenafil, tadalafil, and vardenafil while using nitroglycerin.[7][8][9]

The chronic anal fissure (CAF), is typically more difficult to treat given recurrence and complications. Aside from using nitrates and calcium channel blockers, a third pharmacological method can be employed to prevent a recurrence of CAF. Botulinum toxin (BTX) is generally considered safe and provides significant pain relief. Compared to nitrates and CCBs, BTX is superior and the most effective.

Conservative methods are likely to fail and have a higher failure rate in the chronic recurring anal fissure. In these situations, the gold standard is the lateral internal sphincterotomy (LIS). This surgical procedure treats CAF by preventing hypertonia of the internal sphincter. In a study conducted between 1984 and 1996, 96% of patients undergoing LIS had complete resolution of their CAF within 3 weeks. An open and closed technique can be used in this procedure, under either local or general anesthesia. It has been found that those undergoing LIS with local anesthesia have a higher rate of recurrence of CAF. In the open technique of LIS, an incision is made across the intersphincteric groove. Blunt dissection is then employed to separate the internal sphincter from the anal mucosa. Finally, the internal sphincter is divided with scissors. In the closed technique of LIS, a small incision is made at the intersphincteric groove, and a scalpel is inserted parallel to the internal sphincter. The scalpel is advanced along the intersphincteric groove, and the internal sphincter is then divided by rotating the scalpel toward it. The healing rate is found to be the same with either an open or closed approach.

Although LIS is nearly curative in all cases of CAF, it comes with complications that the healthcare provider should discuss with the patient before the procedure. Fecal incontinence (including uncontrolled flatus, mild stool soiling, and gross incontinence) is the major complication; it occurs in approximately 45% of patients in the immediate postoperative period with a higher likelihood in females (50% versus 30% in males.) Despite the high rate of incontinence, it is transient and usually resolves. Within 5 years of LIS, the rate of incontinence is substantially reduced to less than 10%, with a gross loss of solid stool being less than 1%. Recurrence of CAF in post-LIS patients is approximately 5%, in which conservative methods with pharmacological treatment cures approximately 75%.

Other acute complications from LIS surgery include excessive bleeding that is encountered more commonly during the open technique and may require suture ligation. Approximately 1% of patients undergoing the closed technique develop a perianal abscess, primarily because of the dead space created by the separation of the anal mucosa.

One long-term complication of sphincterotomy that is encountered more frequently in the repair of posterior CAFs is a keyhole deformity. A keyhole deformity is usually asymptomatic and is well tolerated by patients. In a study of over 600 patients undergoing internal sphincterotomy, only 15 developed a keyhole deformity, which was not associated with any anal incontinence, but went on to receive repair.

Differential Diagnosis

An anal fissure is a clinical diagnosis made essentially by physical exam alone and must be done to rule out other possible causes of rectal pain. Hemorrhoids are the most common finding in patients with rectal pain. However, only external hemorrhoids are painful, especially if they are thrombosed. Patients can also have perianal abscesses that cause pain on defecation and can bleed. Perianal abscesses can also form anal fistulas to a deeper site and can either bleed or have purulent drainage. Patients with STIs, inflammatory bowel disease, or TB can form perianal ulcerations. A rare condition, known as solitary rectal ulcer syndrome (SRUS) can also be encountered; however, this lesion has no known cause and is usually found by sigmoidoscopy several centimeters proximal to the anus itself.

Prognosis

Acute anal fissures in low-risk patients typically do well with conservative management and resolve within a few days to a few weeks. However, a percentage of these patients go on to develop CAF, which requires pharmacological treatment and/or surgical management. Over 90% of patients undergoing surgical management achieve cure within 3 to 4 weeks post-operatively.[10]

Complications

  • Bleeding
  • Pain
  • Infection
  • Incontinence
  • Fistula formation- the most serious complication

Enhancing Healthcare Team Outcomes

Anal fissures are a common presentation to the emergency department. Even though benign these lesions can cause significant pain and affect the quality of life. Anal fissures are managed by the nurse practitioner, primary care provider, an emergency room physician, general surgeon, a gastroenterologist, and a colorectal surgeon. The condition can be treated in many ways but when medical treatments fail, it is important to refer the patient to a colorectal surgeon who has more experience with this disorder than most other healthcare providers. The prognosis for most patients is good as long as they make changes in their lifestyle and diet. For recalcitrant cases, surgery may be an option. But even after surgical treatment, these lesions recur in 4-6% of patients. [11][12][13](Level V)

 


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Anal Fissures - Questions

Take a quiz of the questions on this article.

Take Quiz
What treatment is rarely undertaken for anal fistulas?

(Move Mouse on Image to Enlarge)
  • Image 4009 Not availableImage 4009 Not available
    Contributed by Wikimedia Commons, Mcort NGHH (CC by 4.0) https://creativecommons.org/licenses/by/4.0/
Attributed To: Contributed by Wikimedia Commons, Mcort NGHH (CC by 4.0) https://creativecommons.org/licenses/by/4.0/



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What statement is incorrect about anal fistulas?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is false about anal fissures?

(Move Mouse on Image to Enlarge)
  • Image 4703 Not availableImage 4703 Not available
    Contributed by Jonathan Lund, Wikimedia Commons (Public Domain)
Attributed To: Contributed by Jonathan Lund, Wikimedia Commons (Public Domain)



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which condition causes a rectal exam to be near impossible?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not a cause of anal fissure?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is effective for treating anal fissures?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient complains of rectal discomfort and bleeding aggravated by bowel movements. The patient reports a long history of constipation. On examination, there is a small fissure at the lateral 9 o'clock position. Which of the following statements is true?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following deters healing of anal fissures?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
The majority of anal fissures are found at which location?A patient presents with complaints of pain during every bowel movement. He claims the pain often lasts 5-45 minutes afterwards. He is now afraid to have a bowel movement and has developed constipation. Last few days he has seen drops of bright red blood on the toilet paper. On physical exam of the anus, where do you think his pathology is most likely to be found?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the ideal treatment for a patient with chronic anal fissure?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is true regarding anal fissures?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What would not be indicated in the prevention of anal fissures?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is not a consistent symptom in a patient with a diagnosis of anal fissure?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which patient is least at risk for anal fissures?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following concerning anorectal pain is INCORRECT?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient complains of a 2-month history of anal pain with spots of bright red blood on the toilet paper. The pain is much worse with defecation. She has chronic constipation but no anal trauma. Exam shows a skin tag with a linear ulcer. Circular fibers of the sphincter are visible. What is the most appropriate treatment?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the most common confirmation of anal fissure.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the treatment of choice for acute anal fissures?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the most common cause of gastrointestinal bleeding in infants?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Anal Fissures - References

References

Salem AE,Mohamed EA,Elghadban HM,Abdelghani GM, Potential combination topical therapy of anal fissure: development, evaluation, and clinical study†. Drug delivery. 2018 Nov     [PubMed]
Siddiqui J,Fowler GE,Zahid A,Brown K,Young CJ, Treatment of anal fissure: a survey of surgical practice in Australia and New Zealand. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2018 Nov 9     [PubMed]
Carter D,Dickman R, The Role of Botox in Colorectal Disorders. Current treatment options in gastroenterology. 2018 Nov 5     [PubMed]
Choi YS,Kim DS,Lee DH,Lee JB,Lee EJ,Lee SD,Song KH,Jung HJ, Clinical Characteristics and Incidence of Perianal Diseases in Patients With Ulcerative Colitis. Annals of coloproctology. 2018 Jun     [PubMed]
Jamshidi R, Anorectal Complaints: Hemorrhoids, Fissures, Abscesses, Fistulae. Clinics in colon and rectal surgery. 2018 Mar     [PubMed]
Ebinger SM,Hardt J,Warschkow R,Schmied BM,Herold A,Post S,Marti L, Operative and medical treatment of chronic anal fissures-a review and network meta-analysis of randomized controlled trials. Journal of gastroenterology. 2017 Jun     [PubMed]
Mahmoud NN,Halwani Y,Montbrun S,Shah PM,Hedrick TL,Rashid F,Schwartz DA,Dalal RL,Kamiński JP,Zaghiyan K,Fleshner PR,Weissler JM,Fischer JP, Current management of perianal Crohn's disease. Current problems in surgery. 2017 May     [PubMed]
Stewart DB Sr,Gaertner W,Glasgow S,Migaly J,Feingold D,Steele SR, Clinical Practice Guideline for the Management of Anal Fissures. Diseases of the colon and rectum. 2017 Jan     [PubMed]
Vogel JD,Johnson EK,Morris AM,Paquette IM,Saclarides TJ,Feingold DL,Steele SR, Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Diseases of the colon and rectum. 2016 Dec     [PubMed]
Brady JT,Althans AR,Neupane R,Dosokey EMG,Jabir MA,Reynolds HL,Steele SR,Stein SL, Treatment for anal fissure: Is there a safe option? American journal of surgery. 2017 Oct     [PubMed]
Sahebally SM,Meshkat B,Walsh SR,Beddy D, Botulinum toxin injection vs topical nitrates for chronic anal fissure: an updated systematic review and meta-analysis of randomized controlled trials. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2018 Jan     [PubMed]
Salih AM, Chronic anal fissures: Open lateral internal sphincterotomy result; a case series study. Annals of medicine and surgery (2012). 2017 Mar     [PubMed]
Liang J,Church JM, Lateral internal sphincterotomy for surgically recurrent chronic anal fissure. American journal of surgery. 2015 Oct     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of NP-Gerontology Primary Care. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for NP-Gerontology Primary Care, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in NP-Gerontology Primary Care, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of NP-Gerontology Primary Care. When it is time for the NP-Gerontology Primary Care board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study NP-Gerontology Primary Care.