From the Guidelines
Management of anal fissure pain should start with conservative measures, including sitz baths, stool softeners, and topical pain relief, with the goal of reducing anal sphincter pressure and improving blood flow to the area. The primary goals of anal fissure (AF) therapy are to achieve internal anal sphincter (IAS) relaxation, reduce pain, facilitate the healing process, minimize anal trauma, increase blood flow, and treat pain 1. Conservative measures include:
- Sitz baths (warm water soaks) for 10-15 minutes, 2-3 times daily to relax the anal sphincter and improve blood flow
- Stool softeners like docusate sodium (100mg twice daily) and increased dietary fiber (25-30g daily) with adequate water intake to prevent hard stools that can worsen pain
- Topical pain relief with 5% lidocaine ointment applied before bowel movements
- Sphincter relaxation with prescription topical nitroglycerin (0.2-0.4%) or calcium channel blockers like diltiazem (2%) ointment applied 3 times daily for 6-8 weeks
- Over-the-counter pain medications like acetaminophen or ibuprofen to help manage discomfort
According to a recent systematic review and meta-analysis, calcium channel blockers (CCBs) like diltiazem or nifedipine are more effective than glyceryl trinitrate and have fewer side effects, with a healing rate ranging from 65 to 95% 1. The topical use of CCBs is suggested due to the possibility of systemic side-effects and similar rates of healing and pain relief.
If conservative treatment fails after 6-8 weeks, surgical options like lateral internal sphincterotomy may be considered. However, less traumatic techniques like balloon dilatation and staged dilatation have shown healing rates superimposable to those obtained after internal sphincterotomy, with complication and incontinence rates near zero 1.
Key points to consider:
- Conservative measures should be tried for at least 6 weeks before considering surgical options
- Calcium channel blockers like diltiazem or nifedipine are effective and have fewer side effects compared to glyceryl trinitrate
- Less traumatic techniques like balloon dilatation and staged dilatation may be considered before surgical treatment
- Pain control is an essential aspect of anal fissure management, and over-the-counter pain medications like acetaminophen or ibuprofen can be used to manage discomfort.
From the Research
Anal Fissure Pain Management
- Anal fissure is a common anorectal complaint characterized by severe pain with defaecation that persists for one to two hours 2
- The aetiology of anal fissure is unclear, although it is commonly associated with local trauma or chronic conditions 2
- Non-surgical and surgical interventions are available based on the severity and persistence of the fissure 2
Non-Surgical Treatment Options
- Conservative therapy, including dietary fibre and sitz baths, is the first line of treatment for acute anal fissure 2
- Topical nitrates, topical calcium channel blockers, or botulinum toxin injection may be added if conservative treatment fails or at medical discretion 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 achieved healing of chronic anal fissure comparable to 0.2% GTN ointment but with fewer side effects 3
- Botulinum toxin injected into the anal sphincter healed over 80% of chronic anal fissures, but is more invasive and expensive than GTN therapy 3
Comparison of Treatment Options
- GTN was found to be marginally but significantly better than placebo in healing anal fissure, but late recurrence of fissure was common 4
- Botox and calcium channel blockers were equivalent to GTN in efficacy with fewer adverse events 4
- The combination of nifedipine and botulinum toxin was superior to nitroglycerin and pneumatic dilatation with respect to both healing and recurrence rate 5
- Topical nifedipine and botulinum toxin injections are an excellent combination, associated with a low recurrence rate and minimal side effects 5
Surgical Treatment Options
- Surgical sphincterotomy is considered if anal fissure persists despite treatment, but is associated with the risk of faecal incontinence 2, 3, 6
- Internal anal sphincterotomy is the gold standard surgical treatment, which lowers the resting anal pressure and effectively heals the majority of fissures 6