Anal Fistulas and Fissures Medication

Updated: Nov 09, 2018
  • Author: Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Medication

Medication Summary

Medications may also be prescribed for anal fissures, such as topical nitrates, calcium channel blockers, and onabotulinumtoxinA injections, and are considered first-line therapy. [17] These medications reduce anal sphincter tone, which, in turn, increases anodermal blood flow.

Antibiotics may be necessary for the treatment of anal fistulas, especially if the patient presents with systemic symptoms. Postoperative prophylactic antibiotic therapy for 7-10 days (eg, ciprofloxacin, metronidazole) appears to be a key part of preventing anal fistulas after incision and drainage of perianal abscess. [54]

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Laxatives, Bulk-Producing

Class Summary

Psyllium facilitates easier passage of stools.

Psyllium (Fiberall, Metamucil, Konsyl, Reguloid, Natural Fiber Therapy)

Psyllium promotes bowel evacuation by forming a viscous liquid and promoting peristalsis.

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Vasodilators

Class Summary

Vasodilators that cause smooth muscle relaxation are used for relief of anal spasm.

Nitroglycerin rectal (Rectiv)

Organic nitrate is indicated for moderate to severe pain associated with chronic anal fissures. It elicits internal anal sphincter relaxation and reduces sphincter tone and resting intra-anal pressure.

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Anxiolytics, Benzodiazepines

Class Summary

These agents may potentiate the effects of gamma-aminobutyric acid (GABA) and facilitate inhibitory GABA neurotransmission.

Diazepam (Valium, Diastat)

Diazepam is indicated for the relief of severe anal sphincter spasms.

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Antibiotics

Class Summary

Antibiotic therapy must cover both aerobic and anaerobic gram-negative organisms.

Vancomycin

Vancomycin is a potent antibiotic that is directed against gram-positive organisms and is active against Enterococcus species. It is useful in the treatment of septicemia, enterocolitis, and skin-structure infections. Vancomycin is indicated for patients who are unable to receive or have not responded to penicillins and cephalosporins or for patients with resistant staphylococcus infections. Creatinine clearance measurements are used to adjust the dose in patients with renal impairment.

Metronidazole (Flagyl)

Metronidazole is active against various anaerobic bacteria and protozoa. It appears to be absorbed into cells. Intermediate metabolized compounds are formed and bind DNA and inhibit protein synthesis, causing cell death. The antimicrobial effect may be due to production of free radicals.

Ampicillin and sulbactam (Unasyn)

This drug combination of a beta-lactamase inhibitor with ampicillin interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.

Ticarcillin and clavulanate potassium (Timentin)

This drug combination of antipseudomonal penicillin plus a beta-lactamase inhibitor inhibits biosynthesis of cell wall mucopeptide and is effective during the stage of active growth. It provides coverage against most gram-positive, gram-negative, and anaerobic organisms.

Clindamycin (Cleocin)

Clindamycin is effective in the treatment of anaerobic bacteria. It has been shown to have superior effectiveness against streptococci and staphylococci. It continues to be effective against methicillin-resistant Staphylococcus aureus (MRSA).

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Calcium Channel Blockers

Class Summary

Calcium channel blockers work by decreasing resting anal pressures. In a recent review, calcium channel blockers were shown to be as effective as topical nitrates. Oral and topical calcium channel blockers (diltiazem and nifedipine) have been shown to be effective treatment options for anal fissures.

Nifedipine (Nifediac CC, Adalat CC, Procardia, Procardia XL)

Nifedipine is the prototypical dihydropyridine. The topical form is preferred but must be compounded in the pharmacy.

Diltiazem (Cardizem, Cardizem CD, Cartia XT, Dilacor XR, Tiazac)

Diltiazem is a nondihydropyridine that has been reported to be effective. The topical form is preferred but must be compounded in the pharmacy.

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Neuromuscular Blockers, Botulinum Toxins

Class Summary

OnabotulinumtoxinA is used typically to treat muscle hypertonia and cosmetic disorders. Typically, onabotulinumtoxinA is injected into the internal sphincter, reducing hypertonia. Various dosing schemes have been used, and it is typically injected on both sides of the anal fissure. OnabotulinumtoxinA has been shown to be as effective as topical nitrates, but with fewer adverse effects, including headache, and can be an alternative to surgery.

OnabotulinumtoxinA (BOTOX)

OnabotulinumtoxinA is used typically to treat muscle hypertonia and cosmetic disorders. Typically, onabotulinumtoxinA is injected into the internal sphincter, reducing hypertonia.

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