Anal Fissure: Drug Therapy

Therapy goals

  • Improvement of symptomatology, i.e., elimination of pain and reduction of sphincter pressure.
  • Healing of anal fissure

Therapy recommendations

  • Acute anal fissure
    • Antiseptic (agents that destroy bacterial, viral, and other microbial agents of infectious diseases) + local anesthetic (agent for local anesthesia) for external (“external”) therapy) → reduction of resting pressure in the sphincter (sphincter muscle)
    • Local (“local”) therapy with anesthetic (analgesic) ointments or suppositories (suppositories) (e.g., cinchocaine-containing local therapy).
    • If necessary, injection with local anesthetics, local application (application at the site of action) of glycerol trinitrate GTN); alternatively, also use of nitroglycerin or calcium antagonist-containing ointments (e.g., nifedipine) with a treatment duration of 3-8 weeks or at least until the fissure heals (→ relaxation of smooth muscle and lowering of anal resting pressure by release of nitric oxide (NO) = drug-induced sphincter relaxation).
  • Chronic anal fissure
    • Locally (topically) applied calcium antagonists (e.g., nifedipine) or
    • Locally applied nitrates such as glycerol trinitrate GTN); similar high cure rate as calcium antagonists, but more frequent side effects especially headache in 30% of cases.
    • Botulinum toxin (off-label use, ie. Prescription of a finished drug outside the use approved by the drug authorities) into the sphincter (sphincter; acts like a muscle relaxant) – minor but significantly higher cure rates compared to GTN and calcium antagonists [second-line therapy: in therapy resistance to calcium antagonists]Dosage: in hypertonic sphincter first application of a dosage of 20-40 international units of Botox equivalent intrasphincteric (” into the sphincter”).
  • See also under “Surgical therapy” and “Other therapy”.

Further notes

  • If necessary, reduction of sphincter pressure by nitroglycerin or calcium antagonist-containing ointments.
  • Local glucocorticoids should be reserved for patients with secondary diseases, such as a local extreme.
  • Botulinum toxin should not be used for therapy in acute fissures, especially also in view of the high (spontaneous) healing rate, the costs caused, pain due to the application, and the application risks [S3 guideline].
  • Anal dilators can be used for conservative treatment alone or in combination with sphincter-relaxing drugs [S3 guideline].