From the Guidelines
Anal fissures can be effectively treated with a combination of conservative measures and medications, with calcium channel blockers like diltiazem (2%) ointment being a highly effective and recommended first-line option, as shown in a recent systematic review and meta-analysis 1. The primary goals of anal fissure therapy are to achieve internal anal sphincter relaxation, reduce pain, and facilitate the healing process. To obtain these results, the cornerstones of non-operative management are:
- Stool softeners (increased intake of oral fluids, high-fiber diet or fiber supplements, and bulk forming laxatives)
- Sphincter muscle relaxers (warm sitz baths, local application of calcium channel blockers like Diltiazem or Nifedipine, local application of Nitrates like Nitroglycerin and Botulinum injection) Some key points to consider:
- Calcium channel blockers (CCBs) are associated with a healing rate ranging from 65 to 95% and have a remarkable cost-effectiveness compared to other non-operative treatments 1
- Topical use of CCBs is suggested due to the possibility of systemic side-effects and similar rates of healing and pain relief 1
- Administration of therapy for at least 6 weeks is suggested, with pain relief occurring usually after 14 days 1
- Lateral internal sphincterotomy has its own wound-related complications, including fistula, bleeding, abscess, or non-healing wound in up to 3% of patients, and should be considered if conservative and medical treatments fail after 8-12 weeks 1 It is essential to seek medical attention if you experience severe pain, significant bleeding, or if symptoms don't improve within 2-3 weeks of home treatment.
From the Research
Treatment Options for Anal Fissure
- Anal fissure is the second most common anorectal complaint in healthcare settings, and its treatment depends on the severity and persistence of the fissure 2.
- Non-surgical interventions are available, including dietary fibre and sitz baths, and may be supplemented with topical nitrates, topical calcium channel blockers, or botulinum toxin injection if conservative treatment fails 2.
- Surgical options, such as lateral internal sphincterotomy, are considered if the fissure persists despite non-surgical treatment, but may cause permanent injury to the anal sphincter and lead to fecal incontinence 3.
Comparison of Non-Surgical Treatments
- A study comparing botulinum toxin injections and topical nitroglycerin ointment for the treatment of chronic anal fissure found that botulinum toxin was more effective, with a healing rate of 96% compared to 60% for nitroglycerin ointment 3.
- Another study found that the combination of topical nifedipine and botulinum toxin injections was superior to topical nitroglycerin and pneumatic dilatation, with a healing rate of 94% and a low recurrence rate 4.
- A prospective study found that overall healing rates were 64.6% and 94% after medical treatment or botulinum toxin injection/lateral internal sphincterotomy, respectively 5.
Considerations for Treatment
- The choice of treatment depends on the severity and persistence of the fissure, as well as the patient's individual risk factors and medical history 2, 6.
- New interventions are constantly being introduced, and may be of value in patients with high risk of incontinence, but more evidence is needed to support their use 6.
- The goal of treatment is to promote healing of the fissure while minimizing the risk of complications, such as fecal incontinence 3, 5, 4.