How to treat anal fissures
Treatments for anal fissures can be divided into three broad categories:
- conservative medical therapy
- surgical treatments
The choice of treatment for anal fissures depends on the patient history and the features of the disease.
Anal fissures: remedies and prevention
The prevention of fissures is based on a balanced lifestyle, correct hygiene and good food habits. Here are a few tips to alleviate the symptoms of anal fissures in milder cases or to prevent their onset altogether:
- prevent constipation and keep stools soft and hydrated. Reducing exertion during defecation helps prevent the onset of lacerations. The fibres contained in fruit, vegetables, legumes and cereals or supplements will counteract constipation. It is also necessary to take adequate quantities of liquids during the day (at least 1.5 litres).
- prevent diarrhoea, avoiding situations and foods that may trigger it. It is also important to identify any food intolerance which could result in diarrhoea. In particular:
- avoid foods containing gluten in the presence of celiac disease
- avoid lactose
- containing foods in the presence of lactose intolerance
- prevent intestinal infections with proper hygiene and food habits
- prevent alterations of the intestinal bacterial flora with a balanced diet
- avoid or limit the use of laxatives
- carry out regular physical activity to help the bowel function properly.
- adopt a balanced lifestyle, avoiding hectic lifestyles and prolonged stress.
- take care of intimate hygiene with specific products to reduce the risk of inflammation.
Anal fissure: conservative medical therapy
Creams, ointments and emulgel for topical use can help alleviate the symptoms of anal fissures and promote healing.
The goal of conservative medical therapy is to promote the healing of the fissure and to reduce the contraction of the surrounding muscles. Excessive contraction of the sphincter causes hypertonia, which will worsen the symptoms.
Hypertonia is the natural defence reaction of the sphincter muscle which contracts due to the exposure of the lesion. This contraction reduces the blood supply in the area and slows healing.
The products mostly used for the topical treatment of anal fissures are:
Nitroglycerin based ointments
Nitroglycerin ointments aim to reduce the excessive contraction of the internal sphincter.
However, these products have undesirable side effects in a high percentage of cases. The most frequent complication is the onset of headaches which often forces the interruption of the treatment.
Botulinum toxin injections
Botulinum toxin injections in the anal sphincter aim to reduce hypertonia. Botulinum toxin causes a sort of "flaccid paralysis" of the sphincter muscles. This action mechanism should promote the healing of the anal fissure in a matter of months.
However, several studies document the possible onset of faecal incontinence after this therapy.
Calcium channel blocker ointments
Calcium channel blocker ointments act on hypertonia, reducing the maximum sphincter pressure at rest. However, clinical evidence on the effectiveness of this type of therapy is scarce.
One of the main side effects of the treatment is migraine. The risk of overdose in cardiac and diabetic patients is also not negligible.
Ointments based on substances of natural origin
The market offers ointments based on substances of natural origin (creams/emulgels) which alleviate the symptoms of anal fissures and promote healing, without the side effects of traditional treatments. Ask your pharmacist and your doctor for further information.
Anal fissures: surgery
If medical therapies do not give results or if the problem reappears or becomes acute again, surgery may be indicated.
The specialist will identify the most suitable solution among the different surgical techniques available:
Anal divulsion and mechanical anal dilation
Anal divulsion involves dilating the anal orifice for a few minutes (about 1-5 minutes). Dilatation is obtained by inserting both index and middle fingers or special dilators.
This procedure cannot be performed in the presence of hypertonia and intense pain. Conversely, anal divulsion can be useful in cases of mild or medium hypertonia.
Many surgeons consider this technique obsolete. However, in recent years this method has been reintroduced in some surgical centres as "mechanical anal dilation". In this case, anal dilation is obtained by inserting a rubber balloon into the anal canal. The balloon is then inflated under controlled pressure. The procedure is performed under local anaesthesia with sedation to minimise patient discomfort.
One of the side effects of this procedure is the onset of faecal incontinence of varying degrees. Faecal incontinence can be persistent in a considerable percentage of cases.
Lateral internal sphincterotomy
Lateral internal sphincterotomy involves the incision of the lateral portion of the anal sphincter. The incision of the sphincter helps to reduce hypertonia and promotes healing.
Lateral internal sphincterotomy can be performed with the open or closed technique:
- open sphincterotomy: this involves the incision of the skin with sphincter exposure.
- closed sphincterotomy: this is performed subcutaneously without exposing the sphincter.
Both techniques allow healing to be achieved in a high percentage of cases and with a low recurrence rate. Lateral internal sphincterotomy is therefore considered the first-choice intervention for anal fissures.
However, this surgery can cause serious complications, such as faecal incontinence.
Controlled lateral internal sphincterotomy
Lateral internal sphincterotomy can also be performed in a non-standard manner.
In controlled lateral internal sphincterotomy the surgeon can in fact adjust the extent of the incision based on:
- the sphincter length
- the hypertonia severity, measured by anorectal manometry
In this manner, it is possible to reduce the number of unsuccessful cases and to limit the risk of occurrence of faecal incontinence.