From the Guidelines
Chronic anal tears should be initially treated with conservative measures, including warm sitz baths, increased fiber intake, and adequate hydration, followed by topical calcium channel blockers like diltiazem (2%) ointment for 6-8 weeks, as this approach has been shown to be effective with a healing rate ranging from 65 to 95% 1. The primary goal of treatment is to achieve internal anal sphincter (IAS) relaxation, reduce pain, and facilitate the healing process. Conservative measures such as stool softeners, including increased intake of oral fluids, high-fiber diet or fiber supplements, and bulk forming laxatives, are recommended as the first line of treatment.
- Key components of conservative treatment include:
- Warm sitz baths 2-3 times daily for 10-15 minutes
- Increased fiber intake (25-30g daily)
- Adequate hydration (8 glasses of water daily)
- Topical treatments, particularly calcium channel blockers like diltiazem (2%) ointment applied 3 times daily for 6-8 weeks, have been shown to be effective in promoting healing with fewer side effects compared to nitroglycerin ointment 1.
- For pain management, over-the-counter medications like acetaminophen or ibuprofen can help.
- If conservative treatments fail after 6-8 weeks, botulinum toxin injections into the anal sphincter or lateral internal sphincterotomy surgery may be necessary, with the latter having its own wound-related complications, including fistula, bleeding, abscess, or non-healing wound in up to 3% of patients 1. The use of calcium channel blockers is supported by a recent systematic review and meta-analysis, which found that they are more effective than glyceryl trinitrate and have less risk of headache and hypotension 1.
From the Research
Treatment Options for Chronic Anal Tear
- Topical nifedipine with lidocaine ointment has been shown to be effective in healing chronic anal fissure, with a healing rate of 94.5% after 6 weeks of therapy 2
- Glyceryl trinitrate (GTN) ointment has an efficacy of up to 68% in healing chronic anal fissure, but is associated with headache as a major side effect 3
- Diltiazem ointment has been shown to achieve healing of chronic anal fissure comparable to 0.2% GTN ointment, but with fewer side effects 3
- Botulinum toxin injected into the anal sphincter has been shown to heal over 80% of chronic anal fissures, but is more invasive and expensive than GTN therapy 3
- Lateral internal sphincterotomy (LIS) has been shown to be an effective treatment for chronic anal fissure, with a healing rate of 98.7% and no definitive incontinence 4, 5
Pharmacological Agents
- 0.4% nitroglycerin ointment has been shown to significantly increase the rate of decrease in mean visual-analogue-scale pain scores in patients with chronic anal fissure pain 6
- Nifedipine ointment has been shown to be effective in healing chronic anal fissure, with a healing rate of 68.9% after 8 weeks of treatment 5
- Lidocaine has been used in combination with other treatments, such as nifedipine, to treat chronic anal fissure 2, 5
Surgical Treatment
- Lateral internal sphincterotomy (LIS) is a surgical procedure that has been shown to be effective in treating chronic anal fissure, with a healing rate of 98.7% and no definitive incontinence 4, 5
- Botulinum toxin injection into the internal sphincter and fissurectomy is a surgical procedure that has been shown to be effective in treating chronic anal fissure, with a healing rate of 83.3% 4