What are the treatments for chronic (non-healing) anal fissure?
If you present a chronic anal fissure, there is a chance that it will heal on it’s own without any treatment, or just with warm baths and pain relief. However, some persist and treatment helps to heal the fissure as quickly as possible.
Treatment of a chronic anal fissure aims to:
- Relax the muscle tone of the muscle around the anus. This allows a good blood flow and enables the fissure to heal as quickly as possible.
- Keep the faeces soft and easy to pass.
Glyceryl trinitrate or Calcium channel antagonist’s ointment
If you apply glyceryl trinitrate (GTN) or Calcium channel antagonists ointment to the perianal area, it relaxes the muscle around the anus (the anal sphincter). This allows the fissure to heal better. It may also ease the pain very quickly.
About 7 in 10 people with a chronic anal fissure are cured with a course of GTN ointment. (About 5 in 10 will heal in this time with the ‘traditional’ treatment of regular warm baths and using an anaesthetic cream for pain relief.) Therefore, the chance of cure by using GTN is better than the traditional method.
Some points to note if you use GTN ointment include the following:
- There is only one branded product of GTN ointment that is used to treat anal fissure. It is called Rectogesic and is only available on prescription. Rectogesic contains 0.4% GTN. You should use this exactly as described on the leaflet that comes with the packet. For example:
- A standard dose is 2.5 cm squeezed out of the tube. (A measuring line comes with the product to measure 2.5 cm of ointment.)
You squeeze a dose of ointment onto a finger (which you can cover beforehand with cling film or similar). You then place the ointment just inside the anus.
- The ointment is used every 12 hours until pain goes, or for up to 8 weeks maximum. (Some doctors advise to continue with the ointment for a full 6-8 weeks even if the pain goes much sooner. This is because it often takes 6-8 weeks of treatment for the fissure to heal fully, even if the pain has gone.)
- The product leaflet gives details of who should not use the ointment and what side-effects that may occur.
- Up to 6 in 10 people have a headache after applying GTN ointment. (The GTN gets into the bloodstream and may cause a headache.) The headache usually goes within 30 minutes. Painkillers such as paracetamol will help if a headache occurs. If headaches are troublesome, try using a smaller amount of ointment for a few days, and then gradually increase the amount back to normal over several days.
- Another tip if you get bad headaches is to rub a smaller amount of ointment (a pea sized amount) around the rim of your anus rather than inserting the full amount into the anus. GTN is absorbed more into the bloodstream from the thin skin inside the anus. Using a smaller dose of ointment just on the rim of the anus may avoid side-effects (but may not be as effective as using the full dose inserted into the anus.)
- For people aged 12-18, and for people who develop bad side-effects such as headache, your doctor may advise a lower strength of GTN ointment. There is no commercially available ointment that is a lower than 0.4% strength. However, a pharmacist can make up 0.2% strength of ointment by diluting a stronger 2% preparation, which is used for other medical conditions.
Surgery is an option if GTN treatment does not work. It is also an option if you have recurring fissures. The success rate with surgery is very high – at least 9 in 10 cases are cured. The usual operation is to make a small cut in the muscle around the anus (‘internal sphincterotomy’). This permanently reduces the tone (pressure) around the anus and allows the fissure to heal. This is a minor operation, which is usually done as a day-case under general anaesthetic.
However, surgery may cause complications. After this operation, up to 1 in 3 people have poor control of gas (wind), and a small number have soiling of underclothes or mild bowel incontinence.
Prevention of a further anal fissure
If you have had one anal fissure, after it has healed you have a higher than average chance of having another one at some time in the future. The best way to avoid a further fissure is not to become constipated by using the measures described below. That is, a high fibre diet, fluid, etc. Leaflets that list foods high in fibre are commonly available. Ask your practice nurse for one if you cannot obtain one.
Avoiding constipation and keeping faeces soft
- Eat plenty of fibre by eating plenty of fruit, vegetables, cereals, whole meal bread, etc.
- Have lots to drink. Adults should aim to drink at least two litres (10-12 cups) of fluid per day. You will pass much of the fluid as urine, but some is passed out in the gut and softens the faeces. Most sorts of drink will do, but alcoholic drinks can be dehydrating and may not be so good.
- Avoid painkillers that contain codeine such as co-codamol, as they are a common cause of constipation. Paracetamol is preferable to ease the discomfort of a fissure.
- Fibre supplements. If a high fibre diet is not helping, you can take bran, or other fibre supplements (‘bulking agents’) such as ispaghula, methylcellulose, or sterculia. You can buy these at pharmacies or get them on prescription. Methylcellulose also helps to soften faeces directly, which makes them easier to pass.
- Toileting. Don’t ignore the feeling of needing the toilet to pass faeces. Some people suppress this feeling and put off going to the toilet until later. This may result in bigger and harder faeces forming that are more difficult to pass later.