Is EMLA (Eutectic Mixture of Local Anesthetics) okay to use for anal fissures?

EMLA for Anal Fissures: Safety and Efficacy

EMLA (Eutectic Mixture of Local Anesthetics) can be used as a topical analgesic for acute anal fissures as part of conservative management, but it is not a primary treatment for healing the fissure itself.

Initial Management of Anal Fissures

Anal fissures are painful tears in the lining of the anal canal that cause significant discomfort, especially during and after defecation. The management approach should follow these steps:

Conservative Management (First-Line)

• Dietary and lifestyle modifications:
  • Increased fiber intake
  • Adequate hydration
  • Sitz baths (warm water soaks)

Pain Control Options

• Topical anesthetics:
  • EMLA cream (lidocaine-prilocaine mixture) can provide temporary pain relief 1
  • Lidocaine ointment/cream (5%) is commonly prescribed 1
  • These provide symptomatic relief but do not address the underlying cause

Treatment for Healing

For actual healing of the fissure, the following are recommended:

1. Topical muscle relaxants (to reduce internal anal sphincter pressure):

   • Calcium channel blockers (e.g., nifedipine, diltiazem)
   • Nitrates (e.g., glyceryl trinitrate/nitroglycerin)

2. Combination therapy:

   • Some evidence supports combining topical anesthetics with antibiotics
   • A study showed that lidocaine plus metronidazole cream resulted in higher healing rates (86%) compared to lidocaine alone (56%) 2

Evidence for EMLA in Anal Fissures

Research specifically on EMLA for anal fissures shows:

• In a pediatric study, EMLA demonstrated good efficacy with 64% healing rate after 8 weeks of treatment 3
• EMLA provided better pain relief and healing compared to lidocaine alone 3

Important Considerations and Cautions

• EMLA is primarily for pain relief, not for treating the underlying cause of anal fissures
• Duration of use should be limited to avoid potential systemic absorption of local anesthetics
• Avoid manual anal dilatation as this is not recommended by guidelines 1
• Surgical treatment should be considered only for chronic fissures that don't respond to 8 weeks of conservative management 1

When to Seek Further Treatment

Consider alternative or additional treatments if:

• Pain persists despite topical anesthetics
• No improvement after 2-4 weeks of conservative management
• Signs of infection or other complications develop

Algorithm for Management

1. Start with conservative measures (fiber, hydration, sitz baths)
2. Add topical anesthetics like EMLA for pain control
3. Consider adding a topical sphincter relaxant (calcium channel blocker or nitrate)
4. If no improvement after 8 weeks, consider surgical options

EMLA can be a helpful component in managing the pain of anal fissures, but comprehensive treatment should address the underlying sphincter spasm to promote healing.