Page 4 - 01- Anal Fissure

Medical therapy for chronic fissures usually initiated in a stepwise manner when needed:
topical nitrates, topical calcium channel blockers, botulinum toxin injections

MEDICATION
First Line
Acute fissures—50% will heal spontaneously with supportive measures (1)[B].
Stool softeners (docusate) orally daily
Osmotic laxatives orally daily as needed (polyethylene glycol)
Fiber supplements (e.g., psyllium, methylcellulose, inulin) orally daily and increase fluid
intake
Topical analgesics (2% lidocaine gel or 3% cream) 2 to 3 times daily for pain control
Topical lubricants/emollients (Balneol lotion, glycerin ointment, petroleum jelly) for comfort
with defecation
Topical hydrocortisone 1% cream short term for inflammation/pruritus
Sitz baths (sit in plain warm-hot water bath for 10 to 20 minutes) 2 to 3 times daily after bowel
movements

Second Line
Chronic fissures—will not heal without treatment, due to persistent internal sphincter spasm and
ischemia (2)[A]:
Chemical sphincterotomy
– Topical nitroglycerin 0.2–0.4% ointment applied BID; nitroglycerin 0.4% ointment
available commercially (Rectiv): marginally but significantly better than placebo in healing
(48.6% vs. 37%); late recurrence common (50%) (2)[B]; reduces resting anal pressure
through the release of nitric oxide. Headache, hypotension, dizziness are major side effects
(20–30%).
– Topical calcium channel blockers (nifedipine 0.2–0.3% gel, diltiazem 2% ointment),
applied 2 to 4 times per day, relax the internal sphincter muscle, thereby reducing the
resting anal pressure no better than nitrates for healing but fewer side effects consider as
first-line treatment (1)[A]. Oral calcium channel blockers confer lower healing rates, more
side effects, and equal rates of recurrence (3)[A].
– Botulinum toxin 4 mL (20 units) injected into the internal sphincter muscle: no better than
topical nitrates for healing but fewer side effects; inhibits the release of acetylcholine from
nerve endings to inhibit muscle spasm (4)[B]
ISSUES FOR REFERRAL
Late recurrence is common (50%) particularly if the underlying issue remains untreated
(constipation, irritable bowel).
Medical therapy usually tried for 90 to 120 days prior to colorectal surgery referral. Select
patients with chronic fissure may be referred directly for surgical therapy due to proven
superior healing rates (1)[A].

ADDITIONAL THERAPIES
Anococcygeal support (modified toilet seat) may offer some advantage in chronic fissures to
avoid surgery.
SURGERY/OTHER PROCEDURES
Surgery typically reserved for failure of medical therapy