Non surgical therapy for anal fissure.

Nelson RL

Published Online:

October 8, 2008

Anal fissure is a painful ulcer usually occurring in the posterior midline of the skin just outside the entry to the rectum. Its persistence is due to spasm of the internal sphincter muscle. Relief with healing of chronic fissures until very recently has been achieved by surgical procedures aimed at ablation of the sphincter spasm. Because of the the risk of incontinence, medical alternatives for surgery have been sought. Among the older medications, bran is effective in preventing recurrence of acute fissure. Local application of muscle relaxing therapy is effective in healing chronic anal fissure, though not as well as surgery, and with considerable risk of adverse events during therapy.

Abstract (click to read)

Background:

Because of the disability associated with surgery for anal fissure and the risk of incontinence, medical alternatives for surgery have been sought. Most recently, pharmacologic methods that relax the anal smooth muscle, to accomplish reversibly what occurs in surgery, have been used to obtain fissure healing.

Objectives:

To assess the efficacy and morbidity of various medical therapies for anal fissure.

Search strategy:

Search terms include "anal fissure randomized". Timing from 1966 to May 2006. Further details of the search below.

Selection criteria:

Studies in which participants were randomized to a non-surgical therapy for anal fissure. Comparison groups may include an operative procedure, an alternate medical therapy or placebo. Chronic fissure, acute fissure and fissure in children are included in the review. Atypical fissures associated with inflammatory bowel disease or cancer or anal infection are excluded.

Data collection and analysis:

Data were abstracted from published reports and meeting abstracts, assessing method of randomization, blinding, "intention to treat" and drop-outs, therapies, supportive measures (applied to both groups), dosing and frequency and cross-overs. Dichotomous outcome measures included Non-healing of the fissure (a combination of persistence and recurrence), and Adverse events (including incontinence, headache, infection, anaphylaxis). Continuous outcome measures included measures of pain relief and anorectal manometry.

Main results:

48 different comparisons of the ability of medical therapies to heal anal fissure have been reported in 53 RCTs. Eleven agents were used (nitroglycerin ointment (GTN), isosorbide dinitrate, Botulinum toxin (Botox), diltiazem, nifedipine (Calcium channel blockers or CCBs), hydrocortisone, lignocaine, bran, minoxidil, indoramin, and placebo) as well as anal dilators and surgical sphincterotomy.
GTN was found to be marginally but significantly better than palcebo in healing anal fissure (48.6% vs. 37%, p < 0.004), but late recurence of fissure was common, in the rangeof 50% of those intially cured. Botox and CCBs were equivalent to GTN in efficacy with fewer adverse events. No medical therapy cameclose to the efficacy of surgical sphincterotomy, though none in these RCTs was associated with the risk of incontinence.

Authors' conclusions:

Medical therapy for chronic anal fissure, acute fissure and fissure in children may be applied with a chance of cure that is marginally better than placebo, and, for chronic fissure in adults, far less effective than surgery.

This record should be cited as:

Nelson RL. Non surgical therapy for anal fissure. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD003431. DOI: 10.1002/14651858.CD003431.pub2

Assessed as up to date:

July 30, 2006

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Primary Review Group:

Colorectal Cancer Group

Health topics:

Gastroenterology > Non-neoplastic disease of the small & large bowel > Anal fissure

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Non surgical therapy for anal fissure.

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