From the Guidelines
For chronic anal fissures with tenesmus and abdominal distension, I recommend a multi-faceted approach including topical nitroglycerin 0.2% ointment applied to the anal canal twice daily for 6-8 weeks, along with stool softeners such as docusate sodium 100mg twice daily. Start a high-fiber diet (25-30g daily) and increase water intake to at least 2 liters per day to reduce constipation. Sitz baths for 10-15 minutes, 2-3 times daily, especially after bowel movements, can provide significant relief. For pain management, use acetaminophen or ibuprofen as needed. The abdominal distension and tenesmus likely result from altered bowel habits due to pain-induced sphincter spasm. If no improvement occurs within 4-6 weeks, consider calcium channel blockers like diltiazem 2% ointment as an alternative, or referral for botulinum toxin injection or lateral internal sphincterotomy. These treatments work by relaxing the internal anal sphincter, improving blood flow to the fissure area, and allowing healing while addressing the underlying sphincter spasm that perpetuates the condition. Avoid straining during defecation and limit sitting on the toilet to less than 5 minutes to prevent worsening symptoms, as suggested by the American Gastroenterological Association 1.
Some key points to consider:
- The diagnosis of anal fissure is typically made based on history and physical examination, with associated findings such as a sentinel skin tag and hypertrophied anal papilla 1.
- About half of all fissures heal with conservative care, which includes fiber supplementation, adequate fluid intake, sitz baths, and topical analgesics 1.
- Topical nitroglycerin ointment and calcium channel blockers are effective treatments for anal fissures, with the goal of reversibly decreasing resting anal pressure and allowing fissure healing without permanent sphincter damage 1.
- Botulinum toxin injection and lateral internal sphincterotomy are also effective treatments for anal fissures, with high cure rates and low relapse rates 1.
Overall, the goal of treatment is to relieve symptoms, promote healing, and prevent recurrence, while minimizing the risk of complications and improving quality of life.
From the Research
Chronic Anal Fissures
- Chronic anal fissures are a common and painful condition associated with internal anal sphincter hypertonia 2
- Reduction of this hypertonia improves the local blood supply, encouraging fissure healing 2
- Surgical techniques, such as lateral internal sphincterotomy, have been used for over 100 years with success, but postoperative impairment of continence remains controversial 3
Treatment Options
- Topical nitrates, calcium channel blockers, and botulinum toxin are established treatments for chronic anal fissures 3, 2
- Botulinum toxin injection has been shown to be more effective at healing chronic anal fissures than topical glyceryl trinitrate 2
- Chemical sphincterotomy is an effective treatment for chronic anal fissure and has the advantages over surgical treatment of avoiding long term complications and not requiring hospitalisation 2
Complications and Associated Conditions
- Tenesmus and abdominal distension may be associated with chronic anal fissures, although the exact relationship is not well understood
- In patients with inflammatory bowel disease (IBD), the management of hemorrhoids and fissures may be difficult and may significantly differ compared to the non-affected population 4
- Anal fissures in patients with IBD have been overlooked, although they can represent a challenging problem 4
Treatment Outcomes
- A network meta-analysis of randomized controlled trials found that lateral internal sphincterotomy (LIS) is the most efficacious treatment for chronic anal fissures, but is compromised by a high rate of postoperative incontinence 5
- Other treatment options, such as anal dilatation, anoplasty and/or fissurectomy, botulinum toxin, and noninvasive treatment, have lower healing rates and incontinence rates compared to LIS 5