Anal fissures are tears in the lining of the anus, the opening of the rectum to the outside of the body, that cause pain and bleeding during and after bowel movements. In many cases, anal fissures heal on their own within a few weeks. In some cases, though, lingering or worsening tears or extreme pain can prompt a doctor to recommend more aggressive treatment options.
Conservative Treatments
Conservative treatments involve managing the pain and optimizing conditions to allow the fissure to heal on its own. For pain, patients can try warm sitz baths several times per day, or a prescribed or over-the-counter topical corticosteroid medication. To allow healing and prevent recurrence of the fissure, patients must take measures to ensure the bowel movements are soft and easy to pass to prevent further damage to the anus and speed healing. In the short term, patients can use over-the-counter stool softeners and fiber laxatives to prevent constipation. In the long term, patients can promote bowel regularity by ensuring adequate intake of dietary fiber, drinking enough to stay hydrated, and exercising frequently.
Topical Treatments: Nitroglycerin
Nitroglycerin ointment applied to the anus can decrease anal pressure to allow an anal fissure to heal. However, in their medical position statement the American Gastroenterological Association says that healing rates are only about 25 percent to 50 percent in recent clinical trials of nitroglycerin ointment, and that side effects such as headache can be troublesome.
Topical Treatments: Calcium Channel Blockers
Medicated creams containing calcium channel blockers also work by relaxing the anal sphincter to decrease pressure and speed healing. Application of calcium channel blockers to the anus treats anal fissures as effectively as nitroglycerin ointment but with fewer side effects, according to the American Gastroenterological Association.
Botulin Toxin
Botulin toxin (Botox), an agent that temporarily paralyzes muscle fibers, is a newer treatment for anal fissures. When injected in the anus, the toxin induces muscle relaxation that allows the anus to heal itself. The Mayo Clinic says that one injection of botulin toxin can last for up to 3 months, but side effects such as fecal incontinence and increased flatulence might make this a less attractive option. In addition, the American Gastroenterological Association points out that the long-term effectiveness of botulin toxin for treatment of anal fissures is unknown.
Surgery
If an anal fissure causes unbearable pain or if it fails to heal on its own after 6 to 8 weeks, a doctor might recommend surgery. According to the American Gastroenterological Association, most surgeons treating anal fissures prefer to use a procedure called lateral internal sphincterotomy. In this outpatient operation, the surgeon makes a small incision into the internal anal sphincter to reduce anal pressure. Because of the low but serious risk of permanent fecal incontinence after the procedure, surgery is not recommended unless other options have failed.
