From the Guidelines
Anal fissures should be initially treated with conservative measures, including dietary changes and medical interventions, and surgical treatment should be considered only in the chronic phase, after 8 weeks of non-operative management, with lateral internal sphincterotomy being the preferred technique 1.
Treatment Approach
The treatment approach for anal fissures involves a combination of dietary and lifestyle modifications, medical therapy, and surgical intervention when necessary.
- Dietary changes to soften stools, such as increasing fiber intake (25-30g daily) and drinking plenty of water (8-10 glasses daily), can help prevent painful bowel movements.
- Warm sitz baths for 10-15 minutes, 2-3 times daily, can relax the anal sphincter and promote healing.
- Over-the-counter stool softeners like docusate sodium (100mg twice daily) can also be used to prevent painful bowel movements.
Medical Therapy
For medication,
- Topical nitroglycerin ointment (0.2-0.4%) applied to the anal area 2-3 times daily can help relax the sphincter and increase blood flow 1.
- Alternatively, calcium channel blockers like diltiazem (2%) ointment applied 3 times daily for 6-8 weeks may be used.
- Topical anesthetics containing lidocaine can provide temporary pain relief.
Surgical Intervention
If conservative treatments fail after 8 weeks,
- Botulinum toxin injections or surgical procedures like lateral internal sphincterotomy might be necessary 1.
- Lateral internal sphincterotomy has a lower recurrence rate, higher patient satisfaction, and a healing rate of over 90% 1.
Key Considerations
- Patients with acute anal fissure should be managed with a combination of dietary and lifestyle modification and medical therapy, with surgical treatment suggested only in the chronic phase, after the failure of 8 weeks of non-operative management 1.
- Open and closed lateral internal sphincterotomy have similar results, although open lateral internal sphincterotomy may be associated with higher post-operative pain and delayed wound healing at 1 year 1.
From the Research
Anal Fissure Treatment Options
- Non-surgical interventions are available for anal fissure treatment, including dietary changes, sitz baths, and topical medications such as nitrates, calcium channel blockers, or botulinum toxin injection 2, 3, 4, 5
- Surgical options, such as lateral internal sphincterotomy, are considered if the fissure persists despite non-surgical treatment 2, 3, 6
Efficacy of Treatment Options
- Topical nitroglycerin has been found to be marginally but significantly better than placebo in healing anal fissure, but late recurrence of fissure is common 4
- Botulinum toxin and calcium channel blockers have been found to be equivalent to nitroglycerin in efficacy with fewer adverse events 4, 5
- Lateral internal sphincterotomy has been found to be an effective treatment for chronic anal fissure, with a high healing rate and low recurrence rate 3, 6
Comparison of Treatment Options
- A study comparing topical nifedipine and botulinum toxin injections to nitroglycerin and pneumatic dilatation found that the combination of nifedipine and botulinum toxin was superior in terms of healing and recurrence rate 5
- A prospective randomized trial comparing conservative treatment with lateral internal sphincterotomy found that sphincterotomy was more effective in terms of healing rate and pain relief, but had a similar side effect profile 6