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Anal fissure - Treating anal fissure

NHS Choices Medical Reference

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Like other small cuts or tears to the skin, an anal fissure will often heal by itself within a few weeks.

However, you may require treatment to help ease the pain and discomfort that an anal fissure can cause.

You should see your GP if you have the signs and symptoms of an anal fissure because it may be caused by an underlying condition. If this is the case and the condition is not treated, the fissure may not be able to heal and the problem will reoccur.

There are a number of treatments that encourage your anal fissure to heal, as well as easing your pain. These are described below.

Softening stools

Soft stools are easier to pass with less pain and discomfort, so your GP may recommend ways to soften your stools (outlined below).

Laxatives

Laxatives are a type of medicine that can help soften your stools.

Adults with an anal fissure will usually be prescribed a bulk-forming laxative. Bulk-forming laxatives work by helping your stools to retain fluid, making them softer and denser.

Children with an anal fissure are usually prescribed an osmotic laxative. This works by increasing the amount of fluid in your bowels, which stimulates your body to pass stools.

Once you start taking a laxative, your GP may have to adjust the dose until you find that your stools are soft and easy to pass.

Fibre

As well as using laxatives, you should also increase the amount of fibre in your diet. Foods high in fibre include:

  • wholegrain bread
  • brown rice
  • oats
  • beans
  • grains
  • seeds
  • fruit and dried fruit
  • vegetables

Adults should aim to eat at least 18g of fibre a day. You can see how much fibre a food item contains by looking at the nutritional information on the back of the packet.

If you are increasing your fibre intake, you should do so gradually. A sudden increase can cause stomach cramps and make you produce more wind, leaving you feeling bloated. It is also important to make sure that you drink plenty of water. You should aim to drink approximately 1.2 litres (six to eight glasses) of water a day, or more when you are exercising or when it is hot.

Baby wipes or toilet paper

It is important to avoid causing pain or irritation when wiping after passing a stool.

If you use baby wipes, do not use products that contain fragrance or alcohol as this could lead discomfort or itching. If you use toilet paper, use a soft brand if possible and avoid rubbing the area too hard.

Medications

Topical anaesthetics

A topical medicine is one that you apply directly to the affected area. Topical anaesthetics work by desensitising (numbing) the skin, which in the case of an anal fissure, will help ease the sharp and severe pain you may experience when passing stools.

Lidocaine is the most commonly prescribed topical anaesthetic. It either comes in the form of a gel or an ointment. Lidocaine is usually only used for one to two weeks because the fissure should start to heal within this time. It is usually applied shortly before passing a stool, but you should always follow the instructions that come with the medicine.

Painkillers

If you experience prolonged, burning pain after passing stools, you may be prescribed an analgesic (painkiller) such as paracetamol or ibuprofen. Again, you should always follow the dosage instructions on the patient information leaflet or packet.

Glyceryl trinitrate (GTN)

If your symptoms do not start to improve after a week, you may be prescribed a medicine called glyceryl trinitrate (GTN). GTN works by expanding nearby blood vessels, which helps to increase the blood supply to the site of the fissure. The increase in blood supply should enable the fissure heal more quickly.

GTN also reduces anal pressure. This should help reduce the pain. It comes in the form of an ointment and is applied directly to the anal area, usually every 12 hours. 

GTN is not suitable for use by pregnant or breastfeeding women. It is also unsuitable for children. Headaches are a very common side effect of this type of medicine. Approximately 50% of people using GTN will experience a headache. Some people may also feel dizzy or light-headed after using GTN.

You will usually have to use GTN ointment for six to eight weeks, or until your fissure has completely healed.

Calcium channel blockers

Calcium channel blockers are a type of medication usually used to treat high blood pressure (hypertension). However, they have also proved useful in treating cases of anal fissures in some people.

Topical calcium channel blockers work by relaxing the sphincter muscle and increasing the blood supply to the site of the fissure.

Side effects of topical calcium channel blockers may include:

  • headache
  • dizziness, particularly when standing up from a sitting or lying position
  • itchiness or burning at the site when you apply the medication

However, the side effects caused by calcium channel blockers should pass within a few days once your body gets used to the medication.

There is no evidence that calcium channel blockers are more effective than GTN, so they tend only to be used in people unable or unwilling to take GTN.

Botulinum toxin

Botulinum toxin is a relatively new treatment for anal fissures. It's usually used if other treatments have failed.

Botulinum toxin is a powerful poison which is safe to use in small doses. In cases of anal fissure, an injection of the toxin can be used to paralyse your sphincter muscle. This should prevent the muscle from spasming (contracting), helping to reduce pain and allowing the fissure to heal.

Botulinum toxin is an effective treatment in the short to medium term, with three out of four people remaining symptom-free for six months after treatment. Further treatment may be required in the long-term, as around half of people experience a return of their symptoms within three years.

Follow-up

Your GP will usually arrange for you to have a follow-up appointment, approximately eight weeks after the start of your treatment. This will enable them to check that your fissure has healed, or is showing adequate signs of improvement.

If your condition has not been completely treated, your GP may recommend a further follow-up appointment six to eight weeks later.

If your anal fissure is particularly severe, or does not respond to treatment after eight weeks, you may have to be referred to a proctologist (a doctor who specialises in conditions that affect the rectum and anus) for specialist treatment. This will usually involve having some type of surgery.

Surgery

There are a number of different surgical techniques that can be used to treat an anal fissure. These are discussed below.

Internal sphincterotomy

An internal sphincterotomy involves removing a section of the sphincter muscle. This helps to reduce the tension in the muscle, preventing further spasms of the sphincter and allowing the anal fissure to heal.

An internal sphincterotomy is a relatively straightforward operation that can be performed using a local anaesthetic on a day patient basis, which means you will not have to spend the night in hospital.

An internal sphincterotomy is an effective treatment with a good track record of success. Around 95% of people who have this type of surgery will experience healing of their anal fissure.

Around 1 in 10 people will experience bowel incontinence after having surgery due to damage to the anal muscles. This means they will lose some control of their bowel movements. However, it is usually a mild type of incontinence where the person is unable to prevent themselves from passing wind, and they may also experience some mild soiling.

The symptoms of incontinence usually improve in the first few months after surgery and resolve within two months. However, in around 1 in 200 cases the incontinence is permanent.

Read more about bowel incontinence.

Fissurectomy

A fissurectomy is the surgical removal of an anal fissure, along with the surrounding tissue.

Fissurectomies are not as widely used as internal sphincterotomies because they do not treat the underlying causes. Therefore, a fissurectomy may not prevent anal fissures from reoccurring in the future.

However, a fissurectomy may be a recommended treatment option for children because removing a section of the sphincter muscle at an early age could cause permanent incontinence.

Advancement anal flaps

Advancement anal flaps involve taking healthy tissue from another part of your body and using it to repair the fissure and improve the blood supply to the site of the fissure.

This is often recommended to treat cases of chronic anal fissure, which have occurred as a result of pregnancy or other injury to the anus.

Medical Review: May 21, 2012
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