From the Guidelines
Anal fissures should initially be managed with conservative measures, including dietary modifications and topical therapy with calcium channel blockers, as they have been shown to be effective in promoting healing and reducing symptoms, with a healing rate ranging from 65 to 95% 1. The primary goals of anal fissure therapy are to achieve internal anal sphincter relaxation, reduce pain, and facilitate the healing process. Conservative measures, such as stool softeners, increased intake of oral fluids, and high-fiber diet or fiber supplements, can help prevent constipation and promote healing.
- Sitz baths for 10-15 minutes, 2-3 times daily with warm water can help relieve pain and promote healing.
- Topical calcium channel blockers, such as diltiazem 2% ointment applied 3 times daily for 6-8 weeks, have been shown to be effective in promoting healing and reducing symptoms, with fewer side effects than nitroglycerin 1.
- For pain control, acetaminophen or non-steroidal anti-inflammatory drugs are recommended. If conservative measures fail after 6-8 weeks, surgical options, including lateral internal sphincterotomy, may be considered.
- Chronic or recurrent fissures often result from increased anal sphincter tone causing reduced blood flow to the anal canal, which impairs healing.
- Most acute anal fissures will heal with conservative management, but chronic fissures may require more aggressive intervention 1.
From the Research
Anal Fissure Management Options
- Non-surgical interventions are available for the treatment of chronic anal fissure, including topical nitrates, topical calcium channel blockers, and botulinum toxin injection 2
- Botulinum toxin injection has been shown to be an effective treatment for chronic anal fissure, with a healing rate of 96% in one study 3
- Topical nitroglycerin ointment is also a treatment option, but has been shown to have a lower healing rate than botulinum toxin injection, with a healing rate of 60% in one study 3
- The combination of topical nifedipine and botulinum toxin injections has been shown to be an effective treatment for chronic anal fissure, with a healing rate of 94% and a low recurrence rate 4
Comparison of Treatment Options
- A study comparing botulinum toxin injection and topical diltiazem found that the combination of both treatments was not superior to botulinum toxin injection alone, with a healing rate of 52% and 36.7% respectively 5
- Another study comparing combined botulinum toxin A injection and topical diltiazem with partial lateral internal sphincterotomy found that the latter was associated with a significantly higher cure rate in patients with chronic anal fissures of longer duration 6
- The same study found that combined botulinum toxin A injection and topical diltiazem could be as effective as partial lateral internal sphincterotomy in patients with chronic anal fissure for ≤12 months 6
Considerations for Treatment
- The choice of treatment for chronic anal fissure should be based on the severity and persistence of the fissure, as well as the patient's individual needs and preferences 2
- Surgical options, such as lateral internal sphincterotomy, may be considered if non-surgical treatments are unsuccessful, but may carry a risk of fecal incontinence 3, 6
- The use of botulinum toxin injection and topical diltiazem may be associated with minor and transitory side effects, such as incontinence and headaches 3, 5