From the Guidelines
The recommended treatment for an anal fissure in the emergency department is non-operative management, focusing on dietary and lifestyle changes, and medical therapy, as recommended by the WSES-AAST guidelines 1. The primary goals of anal fissure therapy are to achieve internal anal sphincter 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, are recommended to minimize anal trauma and increase blood flow 1.
- 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 pain and facilitate healing 1.
- Topical anesthetics like lidocaine 5% ointment can be applied before bowel movements to reduce pain.
- For pain management, acetaminophen or NSAIDs are preferred over opioids, which can cause constipation.
- Patients should be advised to increase dietary fiber (25-30 g daily) and fluid intake (at least 8 glasses of water daily).
- Topical nitroglycerin 0.2% ointment applied to the anal canal twice daily may help by promoting blood flow and relaxing the internal anal sphincter. Most anal fissures (80-90%) will heal with these conservative measures within 4-6 weeks. Patients should be referred to a colorectal specialist if symptoms persist beyond this period, as chronic fissures may require additional interventions such as botulinum toxin injections or surgical sphincterotomy. The goal of treatment is to break the cycle of pain, sphincter spasm, and reduced blood flow that prevents healing of the anal mucosa. It is essential to note that manual dilatation is not recommended due to the high risk of incontinence 1, and controlled anal dilatation may be considered in the non-operative management of chronic anal fissures, but the available data are not enough to make a recommendation in the acute setting 1.
From the Research
Treatment Options for Anal Fissure in the Emergency Department
The treatment for anal fissure in the emergency department can vary depending on the severity and chronicity of the condition.
- Topical Nitroglycerin: Topical nitroglycerin (GTN) is one of the medical treatments of choice in chronic anal fissure 2. It has been shown to bring about a significant drop in the maximum anal resting pressure (MARP) and can be used as an initial treatment for chronic anal fissure.
- Lateral Internal Sphincterotomy: Lateral internal sphincterotomy is a surgical procedure that can be used to treat chronic anal fissure 2, 3. It has been shown to be effective in relieving pain and promoting healing, but it requires surgical expertise and can have minor, short-term complications.
- Botulinum Toxin Injection: Botulinum toxin injection is a minimally invasive procedure that can be used to treat chronic anal fissure 4, 3. It has been shown to be effective in promoting healing and reducing anal sphincter pressures, with a low risk of complications.
- Other Treatments: Other treatments for anal fissure include topical glyceryl trinitrate ointment, calcium channel blockade, and alpha-adrenoceptor antagonists 5. However, these treatments are still at a developmental stage and may not be widely available.
Considerations for Treatment
When considering treatment for anal fissure in the emergency department, it is essential to take into account the severity and chronicity of the condition, as well as the patient's medical history and preferences.
- Chronic vs. Acute: The treatment approach may differ for chronic versus acute anal fissures 6. Chronic fissures may require more aggressive treatment, such as lateral internal sphincterotomy or botulinum toxin injection.
- Patient Preferences: Patient preferences and values should be taken into account when deciding on a treatment plan 2. For example, some patients may prefer a minimally invasive procedure like botulinum toxin injection, while others may prefer a more traditional surgical approach.
- Potential Complications: Potential complications of treatment, such as fecal incontinence or minor incontinence for flatus and soiling, should be discussed with the patient 5.