What medications are used to treat anal fissures?

Medications for Anal Fissure

Topical calcium channel blockers (diltiazem or nifedipine) are the first-line pharmacological treatment for anal fissures, with healing rates of 65-95% and fewer side effects than nitrates. 1

First-Line Treatments

Conservative Measures

• Dietary and lifestyle modifications:
  • Increased fiber intake (30-40g daily)
  • Adequate hydration (at least 8 glasses of water daily)
  • Warm sitz baths (promote sphincter relaxation)

Pharmacological Treatments (in order of preference)

1. Topical Calcium Channel Blockers:

   • Diltiazem (2%) or Nifedipine (0.3%): Apply to perianal area 3 times daily
   • Superior efficacy compared to nitrates with fewer side effects 1
   • Nifedipine shows higher remission rates (77.4%) compared to diltiazem (54%) and provides earlier pain relief 2

2. Topical Nitrates:

   • Nitroglycerin (0.2-0.4%): Apply twice daily for 6-8 weeks
   • Less preferred due to common side effect of headaches (can occur in up to 77% of patients) 3
   • Healing rate of approximately 48.9% (vs. 35.5% for placebo) 4

3. Pain Management:

   • Topical anesthetics: Lidocaine (most commonly prescribed) before bowel movements
   • Oral analgesics: Acetaminophen or ibuprofen for breakthrough pain 1

4. Adjunctive Treatments:

   • Topical antibiotics: Consider in cases of poor genital hygiene (metronidazole cream has shown improved healing rates when combined with lidocaine) 5
   • Moisturizing agents: Petroleum jelly or zinc oxide to provide protective barrier 1

Second-Line Treatments

1. Botulinum Toxin Injection:
   • Consider if no improvement after 4-6 weeks of conservative treatment
   • Higher efficacy than topical nitroglycerin (96% vs 60% healing rate) 6
   • Fewer side effects than nitroglycerin with no risk of fecal incontinence 6
   • High cure rates (75-95%) with low morbidity 1

Treatment Duration and Follow-up

• Continue topical treatments for at least 6 weeks 1
• Assess healing at 2-week intervals to monitor progress
• Consider surgical intervention only if non-responsive after 8 weeks of non-operative management 5

Important Considerations

• Avoid manual anal dilatation due to high risk of incontinence (temporary and permanent incontinence rates can reach 30% and 10%, respectively) 5
• Recurrence is common with medical therapy, particularly with nitroglycerin (up to 67% recurrence at 9 months for chronic fissures) 3
• Lateral internal sphincterotomy should be reserved for chronic fissures unresponsive to 8 weeks of medical therapy 5

Pitfalls to Avoid

1. Failing to address dietary factors which are fundamental to treatment success
2. Discontinuing medications prematurely (full course of 6-8 weeks needed)
3. Not providing adequate pain management, which can lead to continued sphincter spasm
4. Missing atypical presentations that may indicate other underlying conditions requiring different treatment

Remember that acute anal fissures respond better to medical therapy than chronic fissures, with healing rates approaching 50% with conservative measures alone 5.