From the Guidelines
Anal fissures, also known as anal rhagades or fissure in ano, should be initially treated with a combination of conservative measures and topical calcium channel blockers, such as diltiazem cream (2%, applied 3 times daily for 6-8 weeks), as they have been shown to be effective in reducing anal sphincter pressure and promoting healing, with a healing rate ranging from 65 to 95% 1.
Treatment Overview
The primary goals of anal fissure (AF) therapy are to achieve internal anal sphincter (IAS) relaxation, reduce pain, and facilitate the healing process.
- Stool softeners, such as increased intake of oral fluids, high-fiber diet or fiber supplements, and bulk forming laxatives, can help prevent hard bowel movements and reduce anal trauma.
- Sphincter muscle relaxers, including warm sitz baths, local application of calcium channel blockers like diltiazem or nifedipine, and local application of nitrates like nitroglycerin, can help reduce IAS tone and promote healing.
Topical Therapy
Topical calcium channel blockers, such as diltiazem cream, have been shown to be effective in treating anal fissures, with a healing rate ranging from 65 to 95% 1.
- Diltiazem cream (2%, applied 3 times daily for 6-8 weeks) is a recommended topical treatment for anal fissures.
- Nitroglycerin ointment (0.2-0.4%, applied to the anal canal 2-3 times daily for 6-8 weeks) can also be used, but it may have more side effects, such as headache, compared to calcium channel blockers.
Surgical Treatment
Surgery, such as lateral internal sphincterotomy, is reserved for chronic fissures that do not respond to conservative treatment after 6-8 weeks.
- Lateral internal sphincterotomy has been shown to be effective in treating chronic anal fissures, but it may have complications, such as incontinence, and wound-related complications, including fistula, bleeding, abscess, or non-healing wound 1.
Pain Management
Pain control is an important aspect of anal fissure treatment.
- Acetaminophen or ibuprofen can be used as needed for pain management.
- Topical treatments, such as diltiazem cream or nitroglycerin ointment, can also help reduce pain and promote healing.
Conclusion is not allowed, so the answer just ends here with the last point.
From the Research
Definition and Symptoms of Anal Fissures
- Anal fissures, also known as anal rhagades, are tears in the lining of the anus, which can cause severe pain and bleeding during and after bowel movements 2.
- The symptoms of anal fissures include severe pain with defecation that persists for one to two hours, and the presentation might be acute or chronic 2.
Treatment Options for Anal Fissures
- Non-surgical and surgical interventions are available based on the severity and persistence of the fissure, with the aim of relieving pain and promoting healing 2.
- Conservative therapy, including dietary fibre and sitz baths, is often the first line of treatment for acute anal fissures 2.
- Topical nitrates, such as 0.4% nitroglycerin ointment, can be used to treat chronic anal fissure pain by reducing the increased anal canal pressure caused by a hypertonic internal anal sphincter 3.
- Botulinum toxin injections have also been shown to be effective in treating chronic anal fissures, with a higher healing rate compared to topical nitroglycerin ointment in some studies 4, 5, 6.
- Surgical options, such as partial lateral internal sphincterotomy, may be considered if the fissure persists despite non-surgical treatment, but may carry a risk of fecal incontinence 5.
Comparison of Treatment Options
- A study comparing botulinum toxin injections and topical nitroglycerin ointment found that botulinum toxin was more effective in healing chronic anal fissures, with a healing rate of 96% compared to 60% for nitroglycerin ointment 4.
- Another study found that combined botulinum toxin A injection and topical diltiazem was as effective as partial lateral internal sphincterotomy in treating chronic anal fissures in patients with fissures of ≤12 months duration, but less effective for longer-duration fissures 5.
- A retrospective study found that the combination of nifedipine and botulinum toxin was superior to nitroglycerin and pneumatic dilatation in terms of healing and recurrence rates 6.