From the Guidelines
The treatment for anal fissure should begin with non-operative management, including dietary and lifestyle changes, as the first-line treatment. This approach is recommended based on moderate quality evidence [ 1 ]. The management of anal fissure typically involves:
- Increased fiber and water intake to soften stool and reduce pain during bowel movements
- Avoidance of manual dilatation, as it is not recommended due to lack of evidence supporting its effectiveness [ 1 ]
- Topical medications, such as nitroglycerin or calcium channel blockers, may be considered to relax the internal anal sphincter and improve blood flow to the area
- Pain management with over-the-counter pain relievers like acetaminophen or ibuprofen
- If conservative treatments fail after 8 weeks, surgical treatment may be considered in the chronic phase [ 1 ]. Lateral internal sphincterotomy is the preferred surgical technique due to its high healing rate and low recurrence rate [ 1 ].
Some key points to consider:
- The choice of treatment depends on the chronicity of the fissure, the severity of its symptoms, and the rate and completeness of its response to conservative care [ 1 ]
- Botulinum toxin injections into the anal sphincter may be considered as an alternative to surgical intervention, but more research is needed to determine its long-term effectiveness and potential impact on continence [ 1 ]
- The goal of treatment is to reduce anal sphincter pressure, improve blood flow to the area, and allow the fissure to heal while minimizing pain and discomfort during bowel movements.
From the Research
Treatment Options for Anal Fissure
The treatment for anal fissure can be divided into non-surgical and surgical interventions, depending on the severity and persistence of the fissure 2.
- Non-surgical interventions:
- 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.
- Calcium channel blockers have been shown to be more effective than glyceryl trinitrate (GTN) with less risk of headache, although the quality of evidence is low 3.
- Surgical interventions:
- Lateral internal sphincterotomy (LIS) is considered if the fissure persists despite non-surgical treatment 2.
- LIS has been shown to be superior to non-surgical therapies in achieving sustained cure of fissure, with a high quality of evidence 3.
- Open LIS and closed LIS appear to be equally efficacious, with a moderate quality of evidence 3.
- Manual anal stretch has been found to perform worse than LIS in the treatment of chronic anal fissure in adults 3.
Comparison of Treatment Outcomes
Studies have compared the outcomes of different treatment options for anal fissure:
- A systematic review and meta-analysis found that LIS is superior to non-surgical therapies, with a high quality of evidence 3.
- A prospective study found that LIS had a higher healing rate (98.7%) compared to botulinum toxin injection (83.3%) and medical therapy (54.5-61.5%) 4.
- A randomized clinical trial found that partial lateral internal sphincterotomy had a higher healing rate (94%) compared to combined botulinum toxin A injection and topical diltiazem (65%) 5.
Adverse Effects and Complications
The adverse effects and complications of different treatment options have also been studied:
- The risk of anal incontinence with LIS has been found to be lower than previously thought, ranging from 3.4 to 4.4% 3.
- A study found that there was no statistical difference between LIS and topical nifedipine group concerning side effects 6.
- Another study found that patients in the partial lateral internal sphincterotomy group experienced significantly higher incontinence scores compared to the botulinum toxin A-diltiazem group 5.