Does Ativan (lorazepam) help with anal fissures?

Ativan (Lorazepam) Does Not Help with Anal Fissures

Ativan (lorazepam) is not recommended for the treatment of anal fissures as there is no evidence supporting its use for this condition. 1, 2 Instead, evidence-based treatments focus on reducing internal anal sphincter hypertonia through other mechanisms.

Pathophysiology and First-Line Treatment

Anal fissures are caused by:

• Mechanical trauma from hard stool passage (though less than 25% of patients report constipation)
• Internal anal sphincter hypertonia leading to decreased anodermal blood flow 1

First-Line Management (Non-Operative):

1. Dietary and lifestyle modifications:

   • Increased fiber (30-40g daily) and water intake (at least 8 glasses)
   • Stool softeners and bulk-forming laxatives 1, 2

2. Topical treatments to reduce pain:

   • Lidocaine (most commonly prescribed topical anesthetic)
   • Common pain killers (acetaminophen, ibuprofen) for breakthrough pain
   • Warm sitz baths 1, 2

Evidence-Based Pharmacological Options

For acute anal fissures that don't respond to conservative measures, the following medications are recommended:

Topical Calcium Channel Blockers:

• 2% Diltiazem or 0.3% Nifedipine - These reduce internal anal sphincter tone and increase local blood flow
• Healing rates range from 65-95% 1, 2
• Nifedipine shows higher remission rates (77.4%) compared to diltiazem (54%) and provides earlier pain relief 3
• Both have fewer side effects than nitrates 2

Topical Nitrates:

• Glyceryl trinitrate (nitroglycerin) ointment
• Acts as a vasodilator to increase blood flow and reduce sphincter tone
• Less effective than calcium channel blockers and associated with more headaches and hypotension 1

Other Options:

• Botulinum toxin injection for refractory cases (75-95% cure rate)
• Can be considered if no improvement after 4-6 weeks of conservative treatment 2

Important Considerations

1. Duration of therapy:

   • Treatment should continue for at least 6-8 weeks
   • Pain relief typically occurs after about 14 days 1
   • Response should be assessed at 2-week intervals 2

2. Adjunctive treatments:

   • Topical antibiotics may be considered in cases of poor genital hygiene 1
   • Metronidazole cream combined with lidocaine has shown improved healing rates compared to lidocaine alone 1

3. Avoid manual dilatation:

   • Manual anal dilatation is strongly discouraged due to high risk of incontinence 1, 2

4. When to consider surgery:

   • Surgical treatment (lateral internal sphincterotomy) should be considered only after failure of 8 weeks of non-operative management 1, 2
   • Surgery has healing rates over 90% but carries risk of permanent minor sphincter impairment 2

Common Pitfalls

• Misdiagnosing hemorrhoids as the cause of anorectal symptoms
• Failing to recognize atypical presentations
• Inadequate trial of conservative treatment
• Premature progression to invasive treatments
• Not addressing dietary and lifestyle factors
• Discontinuing treatments prematurely 2

Remember that approximately 50% of patients with acute anal fissures will heal with conservative measures within 10-14 days 1. However, many patients (59% in one study) may require additional treatment over a longer follow-up period 4.