From the Guidelines
Anal fissures can be effectively treated with a combination of conservative measures and medications, prioritizing calcium channel blockers like diltiazem (2%) ointment due to their high healing rates and low risk of side effects, 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, facilitate the healing process, minimize anal trauma, increase blood flow, and treat pain.
- Stool softeners, such as increased intake of oral fluids, high-fiber diet or fiber supplements, and bulk forming laxatives, can help soften stools and reduce trauma to the anal area.
- Sphincter muscle relaxers, including warm sitz baths, local application of calcium channel blockers like diltiazem or nifedipine, and local application of nitrates like nitroglycerin, can help relax the IAS and promote healing.
- Topical calcium channel blockers, such as diltiazem (2%) ointment, have been shown to be effective in treating anal fissures, with healing rates ranging from 65 to 95% 1.
- The use of botulinum toxin injections or surgical lateral internal sphincterotomy may be considered if conservative treatments fail after 6-8 weeks. The American Gastroenterological Association recommends that about half of all fissures heal with conservative care, which consists of fiber supplementation, adequate fluid intake, sitz baths, and topical analgesics 1. It is essential to note that the literature regarding acute anal fissures is scarce, and the available data are often mixed with those regarding chronic anal fissures, especially regarding muscle relaxers 1. In a single double-blind, randomized, prospective trial on 110 patients with chronic anal fissures, Perrotti et al. demonstrated the effectiveness of an industrially manufactured ointment (0.3% nifedipine; 1.5% lidocaine) 1. A recent systematic review and meta-analysis, including 148 trials and 29 different non-surgical treatments, found that calcium channel blockers (diltiazem or nifedipine) were more effective than glyceryl trinitrate and had less risk of headache and hypotension 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 may be added if conservative treatment fails or at medical discretion 2
- Surgical options are considered if the fissure persists despite treatment 2
Comparison of Non-Surgical Treatments
- Botulinum toxin injection has been shown to be more effective than topical nitroglycerin ointment in healing chronic anal fissure, with a healing rate of 96% compared to 60% 3
- Topical nifedipine and botulinum toxin injections have been found to be an effective combination, with a healing rate of 94% and a low recurrence rate of 2% 4
- Nitroglycerin ointment has been found to be marginally but significantly better than placebo in healing anal fissure, but late recurrence of fissure is common 5
Efficacy of Medical Therapies
- Medical therapies, including topical glyceryl trinitrate, botulinum toxin injection, and topical calcium channel blockers, may be applied with a chance of cure that is marginally better than placebo 5
- However, medical therapies are far less effective than surgery for chronic fissure in adults 5
- Newer agents, such as clove oil, sildenafil, and "healer cream", show promise but lack comparison to more established medications 5
Risks and Side Effects
- Surgical sphincterotomy can cause fecal incontinence, which has led to the investigation of non-surgical treatment options 3, 4
- Botulinum toxin injection has been found to have minimal side effects, with only mild transient flatus incontinence reported in some patients 4
- Topical nitroglycerin ointment can cause headaches, which were reported in 5 patients in one study 3