What are the treatment options for anal fissure?

From the Guidelines

Treatment for anal fissures should begin with conservative measures, including fiber supplementation, adequate fluid intake, sitz baths, and topical analgesics, as about half of all fissures heal with these methods 1. When considering treatment options for anal fissures, it's essential to prioritize the patient's quality of life, morbidity, and mortality. The American Gastroenterological Association's medical position statement on anal fissures provides guidance on diagnosis and care 1.

Conservative Treatment

Conservative care is the initial approach for treating anal fissures, particularly for acute cases. This includes:

• Increasing fiber intake to 25-30 grams daily
• Drinking plenty of water (6-8 glasses daily)
• Taking warm sitz baths for 10-15 minutes 2-3 times daily
• Using stool softeners like docusate sodium (100mg twice daily)
• Applying topical pain relievers such as lidocaine gel 2% before bowel movements to reduce pain

Medical Treatment

For persistent fissures, medical treatment options include:

• Nitroglycerin ointment 0.2% applied to the anal canal 2-3 times daily for up to 8 weeks, which relaxes the internal anal sphincter to improve blood flow and healing
• Calcium channel blockers like diltiazem 2% ointment applied 3 times daily for 8 weeks, which can be effective with fewer side effects than nitroglycerin

Surgical Treatment

If conservative treatments fail after 6-8 weeks, surgical options like lateral internal sphincterotomy (LIS) may be considered. LIS is a procedure of choice for anal fissures that do not resolve with conservative care, offering technical simplicity, minimal morbidity, and high cure rates 1.

Alternative Treatment

Botulinum toxin injections are also an option for treating anal fissures, with high cure rates (75%–95%) and low morbidity, as reported in a relatively small number of studies 1.

The choice of treatment should be based on the chronicity of the fissure, the severity of its symptoms, and the rate and completeness of its response to conservative care, with the goal of minimizing morbidity, mortality, and improving quality of life 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for Anal Fissure

• Medical treatments:
  • Topical nitroglycerin ointment 2, 3
  • Botulinum toxin injection into the internal sphincter 2, 3, 4, 5
  • Topical diltiazem ointment 6
  • Topical nifedipine 4
• Surgical treatments:
  • Lateral internal sphincterotomy (LIS) 2, 5
  • Fissurectomy 2

Efficacy of Treatment Options

• Healing rates:
  • Topical nitroglycerin ointment: 54.5% 2, 60% 3
  • Botulinum toxin injection: 83.3% 2, 96% 3
  • Topical diltiazem ointment: 75% 6
  • Topical nifedipine and botulinum toxin: 94% 4
  • LIS: 98.7% 2, 95% 5
• Recurrence rates:
  • Botulinum toxin injection: 15% 5
  • LIS: 5% 5

Adverse Effects

• Topical nitroglycerin ointment: headaches 3
• Botulinum toxin injection: mild transient flatus incontinence 4, no adverse effects 3
• Topical diltiazem ointment: perianal dermatitis, headaches 6
• LIS: risk of postoperative incontinence, minor degree of flatal incontinence 5