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 topical therapy 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 (IAS) relaxation, reduce pain, facilitate healing, minimize anal trauma, increase blood flow, and treat pain.
- Conservative measures include:
- Increasing fiber intake (25-30g daily)
- Drinking plenty of water (6-8 glasses daily)
- Taking warm sitz baths for 10-15 minutes several times daily
- Using stool softeners like docusate sodium (100mg twice daily)
- Topical medications:
- Calcium channel blockers like diltiazem (2% ointment applied 3-4 times daily) are preferred due to their high healing rates (65-95%) and low risk of side effects 1
- Nitroglycerin ointment (0.2-0.4% applied twice daily) may also be used, but it has a higher risk of side effects like headache
- Pain management:
- Over-the-counter pain relievers such as acetaminophen or ibuprofen can be used
Medical and Surgical Interventions
If conservative treatments fail after 6-8 weeks, other options may be considered:
- Botulinum toxin injections into the anal sphincter to temporarily paralyze the muscle and allow healing
- Lateral internal sphincterotomy, which involves cutting a portion of the anal sphincter muscle to reduce pressure and promote healing, has high success rates (95%) but carries a small risk of fecal incontinence 1
- Balloon dilatation and staged dilatation are less traumatic alternatives to internal sphincterotomy, with healing rates similar to those obtained after internal sphincterotomy and low complication rates 1
From the Research
Treatment Options for Anal Fissures
The treatment options for anal fissures can be categorized into conservative measures, medical treatments, and surgical interventions.
Conservative measures:
- Avoiding constipation through fiber intake is useful to improve symptomatology, achieve healing, and reduce recurrence 2
- Stool softeners and sitz baths may be recommended to help manage symptoms
Medical treatments:
- Topical nitroglycerine ointments can produce a transitory sphincteric relaxation, with a healing rate of about 60% to 70% 2
- However, a study found no significant difference in healing or pain relief between patients treated with Nitroglycerin ointment and those who received a placebo 3
- Local injection of botulinum toxin into the anal sphincter is a effective medical option, nearly as effective as surgery and without significant adverse effects 2
- Topical nifedipine cream has been shown to be effective in healing anal fissures, with a healing rate of 70% after 4 weeks of treatment 4
- Glyceryl trinitrate (GTN) ointment has also been found to be an effective treatment for chronic anal fissure, with a healing rate of 85% after 6 weeks of treatment 5
Surgical interventions:
Comparison of Treatment Options
A retrospective study compared the effectiveness of different nonsurgical treatment options, including nitroglycerin and dilatation versus nifedipine and botulinum toxin 6. The results showed that the combination of nifedipine and botulinum toxin was superior to nitroglycerin and pneumatic dilatation, with a higher healing rate (94% vs 71%) and a lower recurrence rate (2% vs 27%).
Side Effects and Complications
The side effects and complications of different treatment options should be considered when making a decision. For example, topical nitroglycerine ointments may cause headaches, while botulinum toxin injections may cause mild transient flatus incontinence 6. Surgical treatment may result in permanent fecal incontinence in some cases 2.