From the Guidelines
Topical calcium channel blockers, such as diltiazem or nifedipine, are the most effective treatment for anal fissures, with healing rates ranging from 65 to 95% and fewer side effects compared to nitroglycerin ointment. According to a recent systematic review and meta-analysis 1, calcium channel blockers are more effective than glyceryl trinitrate and have a lower risk of headache and hypotension. The topical use of calcium channel blockers is suggested, with a recommended administration duration of at least 6 weeks, and pain relief usually occurring after 14 days.
Some key points to consider when using topical treatments for anal fissures include:
- Increased fiber intake (25-30g daily) to soften stool and reduce straining during bowel movements
- Adequate hydration (8 glasses of water daily) to help prevent constipation
- Sitz baths (warm water soaks for 10-15 minutes 2-3 times daily) to promote relaxation and reduce pain
- Stool softeners like docusate sodium (100mg twice daily) to reduce straining during bowel movements
- Avoiding straining during bowel movements and maintaining good anal hygiene to promote healing and prevent infection
If symptoms do not improve after 8 weeks of topical treatment or if fissures recur frequently, surgical consultation may be necessary for procedures like lateral internal sphincterotomy. However, less traumatic techniques like balloon dilatation and staged dilatation have shown promising results, with healing rates similar to those obtained after internal sphincterotomy and lower complication rates 1.
From the FDA Drug Label
Directions Adults and children over 12 years: ◆ Apply to affected area not more than 3 to 4 times daily Warnings For external use only Do not use ◆ on large areas of the body or on cut, irritated or swollen skin
The lidocaine (TOP) can be used as a topical treatment for anal fissure in adults and children over 12 years, applying to the affected area not more than 3 to 4 times daily 2. However, it is crucial to follow the warnings and use the product only as directed, avoiding application on cut, irritated, or swollen skin 2.
From the Research
Topical Treatment for Anal Fissure
- Topical treatments for anal fissure include glyceryl trinitrate (GTN) ointment, diltiazem ointment, and botulinum toxin injection 3.
- GTN ointment has an efficacy of up to 68% in healing chronic anal fissure, but it is associated with headache as the major and most common side effect 3.
- Diltiazem ointment achieved healing of chronic anal fissure comparable to 0.2% GTN ointment but was associated with fewer side effects 3.
- Topical nitrates, such as nitroglycerin ointment, have been shown to cause nitric oxide-mediated relaxation of the internal anal sphincter, and have been effective in treating anal fissures, with a success rate of 56% in acute fissures and 41% in chronic fissures 4.
- However, topical nitrates are often associated with adverse reactions, such as headaches, which can be severe enough to lead to discontinuation of treatment 4, 5.
- Controlled intra-anal dosing of topical nitroglycerin using a specialized dose-delivery device and anal cannula has been shown to produce a significantly greater reduction in sphincteric pressure and lower incidence of headaches than perianal administration of the same dose of ointment 5.
- Other topical treatments, such as calcium channel blockers (e.g. nifedipine, diltiazem) and botulinum toxin injection, have also been shown to be effective in treating anal fissures, with fewer adverse events than GTN 6, 7.
- A systematic review of 75 RCTs found that GTN was marginally but significantly better than placebo in healing anal fissure, but late recurrence of fissure was common, and that botulinum toxin and calcium channel blockers were equivalent to GTN in efficacy with fewer adverse events 7.