From the Guidelines
The most effective treatment for anal fissures is a combination of conservative measures and medical interventions, with calcium channel blockers being the preferred medical treatment due to their high healing rates and low risk of side effects, as shown in a recent systematic review and meta-analysis 1.
Treatment Options
The primary goals of anal fissure therapy are to achieve internal anal sphincter relaxation, reduce pain, facilitate healing, minimize anal trauma, increase blood flow, and treat pain.
- Conservative measures include:
- Increasing fiber intake (25-30g daily)
- Maintaining adequate hydration
- Using sitz baths (warm water soaks for 10-15 minutes, 2-3 times daily)
- Avoiding straining during bowel movements
- Medical treatments include:
- Topical calcium channel blockers like diltiazem (2% ointment applied 3-4 times daily) or nifedipine (0.2-0.5% ointment applied twice daily), which have been shown to be effective in promoting healing and reducing pain, with healing rates ranging from 65 to 95% 1
- Topical nitroglycerin ointment (0.2-0.4%, applied twice daily for 6-8 weeks), which relaxes the internal anal sphincter to improve blood flow and promote healing
- Botulinum toxin injections into the internal anal sphincter, which can provide temporary relief for 2-3 months
Surgical Options
For chronic or recurrent fissures that don't respond to conservative and medical treatments, surgical options include:
- Lateral internal sphincterotomy, which partially cuts the internal anal sphincter to reduce pressure and promote healing, with success rates of 90-95% 1
- Balloon dilatation and staged dilatation, which have shown healing rates superimposable to those obtained after internal sphincterotomy, with complication and incontinence rates near zero 1 It is essential to note that 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, as stated in the american gastroenterological association medical position statement 1.
From the Research
Treatment Options for Anal Fissures
The treatment options for anal fissures can be categorized into non-surgical and surgical interventions.
- Non-surgical interventions are typically considered first, especially for acute anal fissures, and may include:
- Dietary changes, such as increasing fiber intake
- Sitz baths
- Topical nitrates
- Topical calcium channel blockers
- Botulinum toxin injections
- Surgical options are considered if the fissure persists despite non-surgical treatment and may include lateral internal sphincterotomy (LIS) 2, 3.
Efficacy of Non-Surgical Treatments
Studies have compared the efficacy of different non-surgical treatments for anal fissures.
- A study found that botulinum toxin injections were more effective than topical nitroglycerin ointment in healing chronic anal fissures, with a healing rate of 96% compared to 60% 4.
- Another study found that topical nifedipine and botulinum toxin injections were superior to topical nitroglycerin and pneumatic dilatation in terms of healing rate and recurrence rate 5.
- A systematic review found that medical therapies, including topical glyceryl trinitrate, botulinum toxin injection, and topical calcium channel blockers, were marginally better than placebo in healing anal fissures, but were less effective than surgical sphincterotomy 6.
Surgical Treatment
Surgical treatment, specifically lateral internal sphincterotomy (LIS), is considered an effective treatment for chronic anal fissures, with a high healing rate and low risk of incontinence 3.
- A study found that LIS was more effective than topical nifedipine in healing chronic anal fissures, with a healing rate of 88.2% compared to 68.9% 3.
- However, surgical treatment is typically reserved for patients who have failed non-surgical treatment or have a high risk of complications from non-surgical treatment 2, 3.