Anal Fistulas and Fissures Treatment & Management
- Author: Ingrid Legall, MD; Chief Editor: Robert E O'Connor, MD, MPH more...
Approach Considerations
Treatment of anal fistulas depends on (1) presentation of the patient, (2) evidence of sepsis or a large abscess, or (3) no worrisome findings on physical examination. Intravenous antibiotics, antipyretics, and analgesics are provided as needed. If the patient is septic with hypotension, intravenous fluids or a pressor may be necessary. Depending on the presence of systemic symptoms and the condition of the patient, surgery may be necessary.
For anal fistulas, outpatient follow-up with a surgeon is indicated if consultation did not take place at the time of presentation. Consultation usually is not necessary for anal fissures. An emergent surgical consultation may be necessary for fistulous abscess. A gastroenterologist should be consulted if inflammatory bowel disease is suspected.
In the case of anal fissures, if the patient is having a great deal of pain, a topical anesthetic may be applied. Diet modification is indicated in patients with anal fissures to soften stools. Patients should increase fruits, vegetables, and soluble and insoluble fibers in their diets and increase fluid intake. Psyllium may be prescribed. Most uncomplicated fissures resolve in 2-4 weeks with supportive care.
Use the WASH regimen in treatment of anal fissures, as follows:
- Warm water; shower or sitz bath after bowel movement
- Analgesics
- Stool softener
- High-fiber diet
Pharmacologic Treatment of Fissures
Nifedipine
The application of topical 0.5% nifedipine ointment has been used as a chemical sphincterotomy agent. It has been shown to offer a significant healing rate for acute anal fissure and may prevent it from becoming a chronic fissure. Topical application of clove oil cream has also demonstrated significant benefit in patients with chronic anal fissure.[6]
Nitroglycerin
The use of intra-anal nitroglycerin 0.4% has also been shown to be effective in the treatment of anal fissures. In one study, 75% of patients had improvement by the second week, and 54% were healed after 6 weeks. The most common side effect was severe headache.[7] Another study showed a success rate of about 69% at 2-month follow-up for those who used intra-anal nitroglycerin twice daily for 2 weeks.[8, 6]
In July 2011, the US Food and Drug Administration approved intra-anal nitroglycerin ointment as treatment of moderate to severe pain associated with chronic anal fissures.[9] This therapy may be considered if conservative treatment of acute symptoms of anal fissure fails.
Surgical Treatment of Chronic Fissures
Chronic anal fissures frequently require surgical treatment.[5] All surgical procedures involve stretching or cutting the internal sphincter. Open lateral internal sphincterotomy is considered the treatment of choice for chronic anal fissure.[10, 11] It reduces the hypertonia of the internal anal sphincter, decreases pain, and allows the fissure to heal. Botulinum toxin injection has been shown to be an effective alternative to surgery for the treatment of uncomplicated idiopathic anal fissure.[12, 6]
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