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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.^[18]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.^[56]

Class Summary

Psyllium facilitates easier passage of stools.

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

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

Class Summary

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

Nitroglycerin rectal (Rectiv)

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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.

Class Summary

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

Diazepam (Valium, Diastat)

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

Class Summary

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

Vancomycin

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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)

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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)

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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)

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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)

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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).

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)

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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)

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

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)

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

Questions

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Nelson RL, Thomas K, Morgan J, Jones A. Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012 Feb 15. 2:CD003431. [QxMD MEDLINE Link].
Jonas M, Neal KR, Abercrombie JF, Scholefield JH. A randomized trial of oral vs. topical diltiazem for chronic anal fissures. Dis Colon Rectum. 2001 Aug. 44(8):1074-8. [QxMD MEDLINE Link].
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Joshi MR, Bohara TP, Rupakheti S. Comparison of fissure healing and the incidence of headache among the patients treated with endo- and perianal application of 0.2% glyceryl trinitrate for chronic anal fissure. JNMA J Nepal Med Assoc. 2016 Oct-Dec. 55(204):45-50. [QxMD MEDLINE Link].
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Ala S, Saeedi M, Hadianamrei R, Ghorbanian A. Topical diltiazem vs. topical glyceril trinitrate in the treatment of chronic anal fissure: a prospective, randomized, double-blind trial. Acta Gastroenterol Belg. 2012 Dec. 75(4):438-42. [QxMD MEDLINE Link].
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Brisinda G, Cadeddu F, Mazzeo P, Maria G. Botulinum toxin A for the treatment of chronic anal fissure. Expert Rev Gastroenterol Hepatol. 2007 Dec. 1(2):219-28. [QxMD MEDLINE Link].
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Mentes BB, Guner MK, Leventoglu S, Akyurek N. Fine-tuning of the extent of lateral internal sphincterotomy: spasm-controlled vs. up to the fissure apex. Dis Colon Rectum. 2008 Jan. 51(1):128-33. [QxMD MEDLINE Link].
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FitzDowse AJ, Behrenbruch CC, Hayes IP. Combined treatment approach to chronic anal fissure with associated anal fistula. ANZ J Surg. 2018 Jul-Aug. 88(7-8):775-8. [QxMD MEDLINE Link].
Quah HM, Tang CL, Eu KW, Chan SY, Samuel M. Meta-analysis of randomized clinical trials comparing drainage alone vs primary sphincter-cutting procedures for anorectal abscess-fistula. Int J Colorectal Dis. 2006 Sep. 21(6):602-9. [QxMD MEDLINE Link].
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Media Gallery

Anal Fistulas and Fissures. This patient reported constipation.
Anal Fistulas and Fissures. Anal fissure present in a patient with Crohn disease.

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Author

Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE Chief, Department of Emergency Medicine, Sentara Norfolk General Hospital; Medical Ditector, Sentara Transfer Center; Professor and Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School; Board Member, American Academy of Emergency Medicine

Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians, American College of Healthcare Executives, American Institute of Ultrasound in Medicine, Emergency Nurses Association, Medical Society of Virginia, Norfolk Academy of Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Ingrid Legall, MD Assistant Professor, Department of Emergency Medicine, Florida Hospital-Flagler

Ingrid Legall, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Program Director, Emergency Medicine, Einstein Medical Center Montgomery

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Eugene Hardin, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Anal Fistulas and Fissures Medication

Medication Summary

Laxatives, Bulk-Producing

Class Summary

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

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

Vasodilators

Class Summary

Nitroglycerin rectal (Rectiv)

Nitroglycerin rectal (Rectiv)

Anxiolytics, Benzodiazepines

Class Summary

Diazepam (Valium, Diastat)

Diazepam (Valium, Diastat)

Antibiotics

Class Summary

Vancomycin

Vancomycin

Metronidazole (Flagyl)

Metronidazole (Flagyl)

Ampicillin and sulbactam (Unasyn)

Ampicillin and sulbactam (Unasyn)

Ticarcillin and clavulanate potassium (Timentin)

Ticarcillin and clavulanate potassium (Timentin)

Clindamycin (Cleocin)

Clindamycin (Cleocin)

Calcium Channel Blockers

Class Summary

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

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

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

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

Neuromuscular Blockers, Botulinum Toxins

Class Summary

OnabotulinumtoxinA (BOTOX)

OnabotulinumtoxinA (BOTOX)

Anal Fistulas and Fissures Medication

Medication Summary

Laxatives, Bulk-Producing

Class Summary

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

Vasodilators

Class Summary

Nitroglycerin rectal (Rectiv)

Anxiolytics, Benzodiazepines

Class Summary

Diazepam (Valium, Diastat)

Antibiotics

Class Summary

Vancomycin

Metronidazole (Flagyl)

Ampicillin and sulbactam (Unasyn)

Ticarcillin and clavulanate potassium (Timentin)

Clindamycin (Cleocin)

Calcium Channel Blockers

Class Summary

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

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

Neuromuscular Blockers, Botulinum Toxins

Class Summary

OnabotulinumtoxinA (BOTOX)

References

Tables

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