From the Guidelines
To treat chronic anal itching at night from anal fissures, the most effective approach is to use topical calcium channel blockers, such as diltiazem cream, which have been shown to be more effective than nitroglycerin ointment with fewer side effects, as demonstrated in a recent systematic review and meta-analysis 1. The primary goals of treatment are to achieve internal anal sphincter (IAS) relaxation, reduce pain, facilitate healing, minimize anal trauma, increase blood flow, and treat pain. Key treatment strategies include:
- Stool softeners, such as increased intake of oral fluids, high-fiber diet or fiber supplements, and bulk forming laxatives
- Sphincter muscle relaxers, including warm sitz baths, local application of calcium channel blockers like diltiazem or nifedipine, and local application of nitrates like nitroglycerin
- Pain control, with the use of topical anesthetics or oral pain medications as needed Dietary changes, such as increasing fiber intake to 25-30g daily and drinking 8-10 glasses of water, can help soften stools and reduce symptoms. If symptoms persist beyond 2-3 weeks or worsen, consultation with a healthcare provider is necessary to consider prescription-strength medications or surgical intervention like lateral internal sphincterotomy for definitive treatment, as recommended by the American Gastroenterological Association 1. It is essential to note that the use of calcium channel blockers, such as diltiazem cream, has been associated with healing rates ranging from 65 to 95% and is considered a cost-effective treatment option 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for Chronic Anal Fissures
- Topical nitroglycerin ointment has been shown to be effective in treating chronic anal fissure pain, with a significant increase in the rate of decrease in mean visual-analogue-scale pain scores compared to placebo 2.
- Botulinum toxin injection is also a effective treatment option, with a higher healing rate compared to topical nitroglycerin ointment, and no reported cases of fecal incontinence 3.
- A combination of topical nifedipine and botulinum toxin injections has been shown to be superior to topical nitroglycerin and pneumatic dilatation in terms of healing and recurrence rate, with minimal side effects 4.
Management of Chronic Anal Fissures
- Conservative therapy, including dietary fibre and sitz baths, is often the first line of treatment for acute anal fissures, with the addition of topical nitrates, topical calcium channel blockers, or botulinum toxin injection if conservative treatment fails 5.
- Surgical options are considered if the fissure persists despite treatment, but nonsurgical treatment options are preferred to avoid the risk of fecal incontinence associated with sphincterotomy 5, 4.