Anal fissure medical therapy

Most common cause of anal fissure is straining when constipated. For treatment of constipation, click here. Anal fissures in infants usually self-heal without anything more than frequently changing diapers and treating constipation if it is the cause. The topical therapy is the first line of treatment along with dietary and other conservative measures. Analgesia with lidocaine and vasodilators like nitroglycerin and nifedipine are chiefly used for the topical management. Botulinum toxin can be effective in 89% cases. It is reserved for the people who can’t undergo surgery for high risk of incontinence.

• For many years up until 1995, customary treatment included warm baths, topical anesthetics, stool bulking agents, mechanical anal stretching, and, sometimes, surgery. In 1995, doctors began using nitroglycerine cream (topical 1 percent isosorbide dinitrate) but found it less acceptable for long-term use due to patients developing a tolerance to the drug. In 1998, Italian researchers reported injecting botulinum toxin into the anal sphincter to promote healing by relieving anal spasm through relaxation of the muscle.

• Most common cause of anal fissure is straining when constipated. For treatment of constipation, click here.

• Most anal fissures are shallow or superficial (less than a quarter of an inch or 0.64 cm deep). These fissures self-heal within a couple of weeks. Furthermore, the treatment used for hemorrhoid such as eating a high-fiber diet, using a stool softener, taking a painkiller and having a sitz bath can help.
• Preferred regimen, sitz bath: anus to be immersed in warm water for 10-15 minutes q8-12h for 4 weeks.^{[1][2][3][4][5]}

• Anal fissures in infants usually self-heal without anything more than frequently changing diapers and treating constipation if it is the cause.

• Painful deep chronic fissures, will not heal because of poor blood supply caused by sphincter spasm. Traditionally, surgical operations were required which are both painful and associated with various long-term complications, particularly incontinence in a small proportion of cases.
• Botulinum toxin injection, administered by colorectal surgeons, can also be used to relax the sphincter muscle and its use for this condition was first investigated in 1993.^[6] Botulinum toxin can provide relief in 89% cases.^[7] Combination of medical therapies may offer up to 98% cure rates.^[8][3]
• Botulinum toxin is reserved for the people who can’t undergo surgery due to high risk for incontinence.^[9][10]
• Preferred regimen (1): Botulinum toxin type A (Botox) 10 Units (0.2 ml of 50 U/mL) intrasphincteric q30 days for 16 months.^[11]

The topical therapy is the first line of treatment along with dietary and other conservative measures.^[12] Analgesia and vasodilators are chiefly used for the topical management.^{[4][13][14][15][16][17]}

• Preferred regimen: Lidocaine gel 2-5% to be applied locally as needed.

• Preferred regimen (1): Nitroglycerin 0.2 or 0.4% ointment to be applied rectally q12h for 8 weeks.^[18][19][20]
• Preferred regimen (2): Nifedipine 0.2-0.3% ointment to be applied topically q6-12h.^[21][22]
• Alternative regimen (1): Diltiazem 2% rectal gel q8h for 8 weeks.^[23]
• Alternative regimen (2): Bethanechol 0.1% rectal gel q8h for 8 weeks.

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