From the Guidelines
For anal fissures, I recommend starting with conservative treatments, including stool softeners, increased fiber intake, and sitz baths, along with topical calcium channel blockers like diltiazem (2% ointment) applied 3 times daily, as they have been shown to be effective with fewer side effects compared to nitroglycerin 1. The primary goal of treatment is to achieve internal anal sphincter (IAS) relaxation, reduce pain, and facilitate the healing process.
- Conservative care consists of:
- Stool softeners like docusate sodium (100-300 mg daily)
- Increased fiber intake (25-30 grams daily)
- Sitz baths (warm water soaks for 10-15 minutes, 2-3 times daily)
- Topical therapy is directed at reversibly decreasing resting anal pressure, with a goal of allowing fissure healing without permanent sphincter damage.
- Calcium channel blockers like diltiazem (2% ointment) applied 3 times daily have been shown to be effective with fewer side effects compared to nitroglycerin 1
- Topical nifedipine (0.2-0.3% ointment) can also be used as a prescription option
- Pain management is crucial, and over-the-counter pain relievers like acetaminophen or ibuprofen can help.
- If these treatments don't provide relief within 6-8 weeks, surgical treatment may be considered in the chronic phase, with lateral internal sphincterotomy being a common procedure 1.
- Maintaining soft stools through adequate hydration (6-8 glasses of water daily) is crucial for preventing recurrence and allowing healing. According to the most recent guidelines, surgical treatment is not recommended for acute anal fissures, but may be considered for chronic fissures that are non-responsive to 8 weeks of non-operative management 1.
From the Research
Treatment Options for Anal Fissures
The treatment for anal fissures can be surgical or non-surgical. Non-surgical treatments are preferred to avoid the risk of fecal incontinence associated with surgical procedures like lateral internal sphincterotomy 2.
Non-Surgical Treatments
- Botulinum Toxin Injections: Botulinum toxin injections into the internal anal sphincter have been shown to be effective in healing anal fissures. A study found that 96% of patients who received botulinum toxin injections had their fissures healed after two months, compared to 60% of patients who received nitroglycerin ointment 2. Another study also found botulinum toxin to be more effective than nitroglycerin ointment, with 92% of patients in the botulinum toxin group achieving healing after 2 months 3.
- Nitroglycerin Ointment: Nitroglycerin ointment is another non-surgical treatment option for anal fissures. It works by causing a chemical sphincterotomy, leading to healing of the fissure. A study found that 75% of patients with chronic anal fissures achieved healing with nitroglycerin ointment, but the recurrence rate was high at 67% after 9 months 4. Another study found that nitroglycerin ointment was effective in healing anal fissures, with 60% of patients achieving healing after two months 2.
- Calcium Channel Blockers: Calcium channel blockers, such as nifedipine and diltiazem, have also been used to treat anal fissures. A review of 75 randomized controlled trials found that calcium channel blockers were equivalent to nitroglycerin ointment in efficacy, with fewer adverse events 5.
Comparison of Treatments
A review of 75 randomized controlled trials found that no medical therapy was as effective as surgical sphincterotomy in healing anal fissures, but medical therapies had the advantage of avoiding the risk of incontinence 5. Botulinum toxin injections and calcium channel blockers were found to be more effective than nitroglycerin ointment, with fewer adverse events 5, 3.
Adverse Events
Adverse events associated with non-surgical treatments for anal fissures include headaches, which were common with nitroglycerin ointment 2, 3, 4, and mild incontinence to flatus, which was associated with botulinum toxin injections 3.