From the Guidelines
Anal fissures can be effectively treated with a combination of conservative measures and medical interventions, with calcium channel blockers being the most effective topical treatment, as shown in a recent systematic review and meta-analysis 1. The primary goals of anal fissure therapy are to achieve internal anal sphincter (IAS) relaxation, reduce pain, and facilitate the healing process. Conservative measures include:
- Stool softeners, such as increased intake of oral fluids, high-fiber diet or fiber supplements, and bulk forming laxatives
- Sphincter muscle relaxers, including warm sitz baths, local application of calcium channel blockers like diltiazem or nifedipine, and local application of nitrates like nitroglycerin
- Pain management with acetaminophen or ibuprofen as directed Topical treatments, such as calcium channel blockers (diltiazem or nifedipine) and nitroglycerin ointment, can be used to relax the anal sphincter and improve blood flow.
- Calcium channel blockers, such as diltiazem (2%) or nifedipine (0.2-0.5%) ointment, are associated with healing rates ranging from 65 to 95% and have fewer side effects compared to nitroglycerin ointment 1. If conservative treatments fail after 6-8 weeks, botulinum toxin injections or surgical lateral internal sphincterotomy may be considered.
- Lateral internal sphincterotomy has its own wound-related complications, including fistula, bleeding, abscess, or non-healing wound in up to 3% of patients 1. It is essential to note that the available data on acute anal fissures are scarce, and most studies focus on chronic anal fissures.
- Controlled anal dilatation, including balloon dilatation and staged dilatation, may be considered as a non-operative management option, but more research is needed to confirm its effectiveness in the acute setting 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 (LIS), are considered if the fissure persists despite treatment 2, 3
Efficacy of Different Treatments
- A study found that the overall healing rate for chronic anal fissure was 64.6% with nitroglycerin ointment (GTN) or anal dilators (DIL), and 94% with botulinum toxin injection or LIS 3
- Another study compared botulinum toxin injection and topical nitroglycerin ointment, and found that botulinum toxin was more effective, with a healing rate of 96% compared to 60% for nitroglycerin ointment 4
- A review of pharmacological agents for chronic anal fissure found that glyceryl trinitrate (GTN) ointment had an efficacy of up to 68%, but was associated with headache as a side effect, while botulinum toxin injection had a healing rate of over 80% but was more invasive and expensive 5
Comparison of Nonsurgical Treatments
- A retrospective study compared the efficacy of nitroglycerin and dilatation versus nifedipine and botulinum toxin for the treatment of chronic anal fissure, and found that the combination of nifedipine and botulinum toxin was superior, with a healing rate of 94% and a low recurrence rate 6
- The study also found that the combination of nifedipine and botulinum toxin had minimal side effects, with only three patients reporting mild transient flatus incontinence 6