From the Guidelines
Treatment for anal fissures should begin with conservative measures, including increased fiber intake, adequate hydration, and warm sitz baths, as these methods are risk-free and can promote healing, as noted in the American Gastroenterological Association medical position statement 1.
Conservative Measures
Conservative measures are the first line of treatment for anal fissures, as they are non-invasive and can be effective in promoting healing. These measures include:
- Increased fiber intake (25-30g daily) to soften stools
- Adequate hydration (8-10 glasses of water daily) to prevent constipation
- Warm sitz baths for 10-15 minutes, 2-3 times daily, to reduce pain and promote relaxation
- Over-the-counter stool softeners like docusate sodium (100mg twice daily) to prevent constipation
- Pain management with acetaminophen or ibuprofen as needed
Topical Therapy
If conservative measures do not provide relief within 1-2 weeks, topical medications may be prescribed, including:
- Nitroglycerin ointment (0.2-0.4%, applied to the anal canal 2-3 times daily), which relaxes the internal anal sphincter, as discussed in the American Gastroenterological Association medical position statement 1
- Calcium channel blockers like diltiazem (2% ointment applied 3 times daily), which can also relax the internal anal sphincter
Botulin Toxin Injections
Botox injections into the anal sphincter may be considered for persistent fissures, as they have been shown to have high cure rates (75%–95%) and low morbidity rates, as noted in the study on botulin toxin injections 1.
Surgical Options
For chronic fissures that do not respond to conservative treatment after 6-8 weeks, surgical options like lateral internal sphincterotomy may be necessary, as they can provide rapid and effective relief, but may carry a risk of permanent minor sphincter impairment, as discussed in the American Gastroenterological Association medical position statement 1.
From the Research
Treatment Options for Anal Fissure
- Non-surgical interventions are available for the treatment of anal fissure, including dietary fibre and sitz baths 2
- Topical nitrates, topical calcium channel blockers, or botulinum toxin injection can be added if conservative treatment fails or at medical discretion 2
- Surgical options, such as lateral internal sphincterotomy, are considered if the fissure persists despite treatment 2, 3, 4, 5
Nonsurgical Treatment
- A study comparing topical nitroglycerin and pneumatic dilatation with topical nifedipine and botulinum toxin injections found that the combination of nifedipine and botulinum toxin was superior in terms of healing and recurrence rates 3
- Botulinum toxin injection has been shown to be an effective treatment for chronic anal fissure, with a healing rate of 96% in one study 6
- Topical nifedipine has also been found to be effective in treating chronic anal fissure, with a healing rate of 68.9% in one study 5
Surgical Treatment
- Lateral internal sphincterotomy has been found to be an effective treatment for chronic anal fissure, with a healing rate of 88.2% in one study 5
- Surgical treatment has been found to have a lower recurrence rate compared to nonsurgical treatment 4
- However, surgical treatment carries a risk of incontinence, although this risk may be overestimated 5