From the Guidelines
The most effective outpatient treatment for anal fissures is a combination of conservative measures and topical medications, with calcium channel blockers being a preferred option due to their efficacy and lower side effect profile compared to nitroglycerin ointment 1. When managing anal fissures, it is essential to start with conservative measures, including increased fiber intake, adequate hydration, and warm sitz baths.
- Increased fiber intake of 25-30g daily can help soften stool and reduce straining during bowel movements.
- Adequate hydration of at least 8 glasses of water daily can also contribute to softer stool.
- Warm sitz baths for 10-15 minutes, 2-3 times daily, can help relax the anal sphincter and increase blood flow to the area. For medication therapy, topical calcium channel blockers such as diltiazem (2%) or nifedipine (0.2-0.5%) ointment applied 3 times daily for 6-8 weeks are effective alternatives to nitroglycerin ointment, with fewer side effects 1.
- These treatments work by reducing anal sphincter pressure, improving blood flow to the area, and allowing the fissure to heal. If symptoms persist beyond 6-8 weeks of conservative treatment, surgical consultation is recommended as chronic fissures may require lateral internal sphincterotomy, which has the highest healing rate but is reserved for persistent cases 1. It is crucial to note that about half of all fissures heal with conservative care, and acute fissures are more likely to heal than chronic ones 1.
- The timing and choice of additional treatment depend on the chronicity of the fissure, the severity of its symptoms, and the rate and completeness of its response to conservative care.
From the Research
Outpatient Treatments for Anal Fissure
The following are some of the outpatient treatments for anal fissure:
- Dietary fibre and sitz baths as conservative therapy 2
- Topical nitrates, topical calcium channel blockers, or botulinum toxin injection for patients who do not respond to conservative treatment 2, 3
- Pharmacologic methods that relax the anal smooth muscle, such as nitroglycerin ointment, isosorbide mono- and dinitrate, and diltiazem 3
Efficacy of Outpatient Treatments
The efficacy of these treatments varies:
- Topical nitroglycerin was found to be marginally but significantly better than placebo in healing anal fissure, but late recurrence of fissure was common 3, 4
- Botulinum toxin injection and calcium channel blockers were equivalent to topical nitroglycerin in efficacy, but with fewer adverse events 3, 5
- Calcium channel blockers were more effective than glyceryl trinitrate and with less risk of headache, but with only a low quality of evidence 6
Comparison of Outpatient Treatments
Comparisons between different outpatient treatments have been made:
- Fissurectomy followed by topical diltiazem cream may be as good as fissurectomy with botulinum toxin injection in the treatment of chronic anal fissure 5
- Glyceryl trinitrate was more effective than control in sustained cure, but the quality of evidence was very poor due to severe heterogeneity and risk of bias 6