From the Guidelines
Treatment for anal fissures should begin with conservative measures, including increasing fiber intake, drinking plenty of water, taking warm sitz baths, and using stool softeners, before considering surgical options or other treatments like topical therapy or botulinum toxin injections. 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 1. Conservative care is risk-free but has a relatively low success rate and takes a long time, whereas lateral internal sphincterotomy (LIS) carries a risk of permanent minor sphincter impairment but works rapidly and effectively 1.
Some key treatment options for anal fissures include:
- Increasing fiber intake to 25-30 grams daily
- Drinking plenty of water (6-8 glasses daily)
- Taking warm sitz baths for 10-15 minutes several times a day
- Using stool softeners like docusate sodium (100-300 mg daily)
- Topical pain relievers such as lidocaine gel 2% applied before bowel movements to reduce pain
- Prescription medications like nitroglycerin ointment 0.2% or calcium channel blockers like diltiazem 2% ointment applied to the anal area for up to 8 weeks
- Botulinum toxin injections for temporary sphincter relaxation when other treatments fail
According to a recent systematic review and meta-analysis, calcium channel blockers (diltiazem or nifedipine) are more effective than glyceryl trinitrate and have fewer side effects, with a healing rate ranging from 65 to 95% 1. The use of calcium channel blockers like diltiazem 2% ointment applied 3 times daily for 6-8 weeks is recommended as a first-line treatment for anal fissures due to their high efficacy and low risk of side effects. If conservative measures fail after 6-8 weeks, surgical options like lateral internal sphincterotomy may be recommended, which has a high success rate but carries a small risk of incontinence 1.
From the Research
Treatment Options for Anal Fissure
The treatment options for anal fissure include:
- Non-surgical therapies, such as topical nitroglycerin ointment 2, 3, 4, 5 and botulinum toxin injections 2, 3
- Medical therapies, including calcium channel blockers (e.g. nifedipine, diltiazem) 6
- Surgical sphincterotomy, which is more effective than medical therapies but carries a risk of incontinence 6
Efficacy of Treatment Options
The efficacy of these treatment options varies:
- Topical nitroglycerin ointment has been shown to be effective in healing anal fissures, but with a high recurrence rate 4
- Botulinum toxin injections have been found to be more effective than topical nitroglycerin ointment in some studies 2, 3
- Calcium channel blockers have been found to be equivalent to topical nitroglycerin ointment in efficacy, with fewer adverse events 6
- Surgical sphincterotomy is the most effective treatment option, but carries a risk of incontinence 6
Adverse Events
Adverse events associated with these treatment options include: