Anal fissure medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]
Overview
Medical Therapy
- 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
Symptomatic
- 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.[1][2][3]
Pediatric
- Anal fissures in infants usually self-heal without anything more than frequently changing diapers and treating constipation if it is the cause.
Chemical Sphincterotomy
- 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.
- Local application of medications to relax the sphincter muscle, thus allowing the healing to proceed, was first proposed in 1994 with nitroglycerine ointment,[4][5][6] in 1999 with nifedipine ointment,[7][8] and the following year with topical diltiazem.[9]
- 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.[10] Combination of medical therapies may offer up to 98% cure rates.[11] These medical treatments are used as first line therapy in treating chronic anal fissures,[12] although a Cochrane Collaboration review of published research has questioned the effectiveness of medical treatments compared to surgery.[13]
Topical medical therapy
The topical therapy is the first line of treatment along with dietary and other conservative measures. Analgesia and vasodilators are chiefly used for the topical management.[3][14][15][16][17][18]
Topical analgesic
- Preferred regimen: Lidocaine jelly 2-5% to be applied locally as needed.
Topical vasodilators
- Preferred regimen (1): Nitroglycerin 0.2 or 0.4% ointment to be applied rectally q12h for 8 weeks.
- Preferred regimen (2): Nifedipine 0.2-0.3% ointment to be applied topically q6-12h.
- Alternative regimen (1): Diltiazem 2% rectal gel q8h for 8 weeks.
- Alternative regimen (2): Bethanechol 0.1% rectal gel q8h for 8 weeks.
References
- ↑ Wald A, Bharucha AE, Cosman BC, Whitehead WE (2014). "ACG clinical guideline: management of benign anorectal disorders". Am. J. Gastroenterol. 109 (8): 1141–57, (Quiz) 1058. doi:10.1038/ajg.2014.190. PMID 25022811.
- ↑ Gupta P (2006). "Randomized, controlled study comparing sitz-bath and no-sitz-bath treatments in patients with acute anal fissures". ANZ J Surg. 76 (8): 718–21. doi:10.1111/j.1445-2197.2006.03838.x. PMID 16916391.
- ↑ 3.0 3.1 Jensen SL (1986). "Treatment of first episodes of acute anal fissure: prospective randomised study of lignocaine ointment versus hydrocortisone ointment or warm sitz baths plus bran". Br Med J (Clin Res Ed). 292 (6529): 1167–9. PMC 1340178. PMID 3011180.
- ↑ Loder P, Kamm M, Nicholls R, Phillips R (1994). "'Reversible chemical sphincterotomy' by local application of glyceryl trinitrate". Br J Surg. 81 (9): 1386–9. PMID 7953427.
- ↑ Watson S, Kamm M, Nicholls R, Phillips R (1996). "Topical glyceryl trinitrate in the treatment of chronic anal fissure". Br J Surg. 83 (6): 771–5. PMID 8696736.
- ↑ Simpson J, Lund J, Thompson R, Kapila L, Scholefield J (2003). "The use of glyceryl trinitrate (GTN) in the treatment of chronic anal fissure in children". Med Sci Monit. 9 (10): PI123–6. PMID 14523338.
- ↑ Antropoli C, Perrotti P, Rubino M, Martino A, De Stefano G, Migliore G, Antropoli M, Piazza P (1999). "Nifedipine for local use in conservative treatment of anal fissures: preliminary results of a multicenter study". Dis Colon Rectum. 42 (8): 1011–5. PMID 10458123.
- ↑ Katsinelos P, Kountouras J, Paroutoglou G, Beltsis A, Chatzimavroudis G, Zavos C, Katsinelos T, Papaziogas B (2006). "Aggressive treatment of acute anal fissure with 0.5% nifedipine ointment prevents its evolution to chronicity". World J Gastroenterol. 12 (38): 6203–6. PMID 17036396.
- ↑ Carapeti E, Kamm M, Phillips R (2000). "Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects". Dis. Colon Rectum. 43 (10): 1359–62. PMID 11052511.
- ↑ Jost W, Schimrigk K (1993). "Use of botulinum toxin in anal fissure". Dis Colon Rectum. 36 (10): 974. PMID 8404394.
- ↑ Tranqui P, Trottier D, Victor C, Freeman J (2006). "Nonsurgical treatment of chronic anal fissure: nitroglycerin and dilatation versus nifedipine and botulinum toxin" (PDF). Canadian journal of surgery. Journal canadien de chirurgie. 49 (1): 41–5. PMID 16524142.
- ↑ Haq Z, Rahman M, Chowdhury R, Baten M, Khatun M (2005). "Chemical sphincterotomy--first line of treatment for chronic anal fissure". Mymensingh Med J. 14 (1): 88–90. PMID 15695964.
- ↑ Nelson R (2006). "Non surgical therapy for anal fissure". Cochrane database of systematic reviews (Online) (4): CD003431. PMID 17054170.
- ↑ Davies D, Bailey J (2017). "Diagnosis and Management of Anorectal Disorders in the Primary Care Setting". Prim. Care. 44 (4): 709–720. doi:10.1016/j.pop.2017.07.012. PMID 29132530.
- ↑ Schlichtemeier S, Engel A (2016). "Anal fissure". Aust Prescr. 39 (1): 14–7. doi:10.18773/austprescr.2016.007. PMC 4816871. PMID 27041801.
- ↑ Carapeti EA, Kamm MA, Phillips RK (2000). "Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects". Dis. Colon Rectum. 43 (10): 1359–62. PMID 11052511.
- ↑ Knight JS, Birks M, Farouk R (2001). "Topical diltiazem ointment in the treatment of chronic anal fissure". Br J Surg. 88 (4): 553–6. doi:10.1046/j.1365-2168.2001.01736.x. PMID 11298624.
- ↑ Jonas M, Speake W, Scholefield JH (2002). "Diltiazem heals glyceryl trinitrate-resistant chronic anal fissures: a prospective study". Dis. Colon Rectum. 45 (8): 1091–5. PMID 12195195.