From the Guidelines
Treatment for anal fissures should begin with non-operative management, including dietary and lifestyle changes, as the first-line treatment, as recommended by the most recent guidelines 1. This approach is supported by the World Journal of Emergency Surgery, which suggests that non-operative management is the preferred initial treatment for acute anal fissures 1. The primary goals of this treatment are to achieve internal anal sphincter relaxation, reduce pain, facilitate the healing process, minimize anal trauma, increase blood flow, and treat pain.
Some key components of non-operative management include:
- Increased fiber intake (25-30g daily) and water intake to prevent constipation
- Warm sitz baths 2-3 times daily to relax the anal sphincter and improve blood flow
- Stool softeners like docusate sodium (100mg twice daily) to prevent constipation
- Over-the-counter pain relievers such as acetaminophen or ibuprofen to manage discomfort
- Topical medications, such as calcium channel blockers like diltiazem (2% ointment applied 3-4 times daily), which have been shown to be effective in reducing anal sphincter pressure and promoting healing, with a healing rate ranging from 65 to 95% 1.
If conservative and medical treatments fail after 6-8 weeks, surgical options may be considered, with lateral internal sphincterotomy being the most common procedure 1. However, this should be considered a last resort, as it carries a risk of minor, but sometimes permanent, defects in continence 1.
It's worth noting that manual dilatation is no longer recommended due to the high risk of incontinence and the superiority of internal sphincterotomy 1. Controlled anal dilatation may be considered as an alternative to surgical treatment, but more research is needed to fully understand its effectiveness in the acute setting 1.
From the Research
Treatment Options for Anal Fissure
The treatment for anal fissure can be divided into non-surgical and surgical interventions.
- Non-surgical treatments include:
- Surgical options are considered if the fissure persists despite non-surgical treatment, with lateral internal sphincterotomy being a common procedure 2, 6, 5
Effectiveness of Treatments
- Botulinum toxin injection has been shown to be an effective treatment for chronic anal fissure, with a high healing rate and minimal side effects 2, 4, 6
- Topical nitroglycerin ointment is also effective, but may have more side effects such as headaches 2
- The combination of topical nifedipine and botulinum toxin injections has been shown to be superior to nitroglycerin and pneumatic dilatation in terms of healing and recurrence rates 4
- Partial lateral internal sphincterotomy has a higher healing rate than combined botulinum toxin A injection and topical diltiazem for chronic anal fissures of longer duration 6
Considerations for Treatment
- The choice of treatment depends on the severity and persistence of the fissure, as well as the patient's willingness to accept the potential risks and benefits of each treatment option 3, 5
- Non-surgical treatments are generally considered first-line, with surgical options reserved for patients who do not respond to conservative treatment 3, 5