Treating anal fissures

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

However, you should see your GP if you have an anal fissureas they can give you advice and medications to help ease your symptoms and allow the fissure to heal more quickly.

Most anal fissures will heal with treatment, although they can recur easily, particularly if you don't follow the self-help advice outlined below.

Self-help

There are a number of self-help measures your GP may recommend to relieve Constipation and reduce the pain caused by anal fissures.

Relieving constipation can allow anal fissures to heal and reduce the chances of further fissures developing in the future.

Self-help measures include:

• increasing your daily intake of fibre by including plenty ofhigh-fibre foods in your diet, such asfruit, vegetables and wholegrains
• avoiding dehydration by drinking plenty of water
• trying to get more exercise for example, by going for a daily walk or run
• working out a place and time of day when you can comfortably spend time on the toilet
• not delaying going to the toilet when you feel the urge
• ifyou use wet wipes, avoiding products that contain fragrance or alcohol as this could lead to discomfort or itchingif you use toilet paper, use a soft brand and avoidwiping too hard
• soaking your bottom in a warm bath several times a day, particularly after a bowel movement, to relax the muscles in your anus

See preventing anal fissures for more self-help advice.

Medications

There are a number of different medications your GP may recommend to help reduce your symptoms and allow your anal fissure to heal.

Laxatives

Laxatives are a type of medicine that can helpyou pass stools more easily.

Adults with an anal fissure will usually be prescribed bulk-forming laxative tablets or granules. These work by helping your stools retain fluid, making them softer and less likely to dry out.

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

Your GP may recommend starting treatmentat a low dose and gradually increasing it every few days until you're able to pass soft stools every one or two days.

Painkillers

If you experience prolonged burning pain after passing stools, your doctor may recommend taking common over-the-counter painkillers, such as paracetamol or ibuprofen.

If you decide to take these medications, make sure you follow the dosage instructions on the patient information leaflet or packet.

Glyceryl trinitrate

If your symptoms don't improve within a week or two, your GP may prescribe a medication called glyceryl trinitrate (GTN), an ointment applied directly to the anal area, usually twice a day.

GTN works by expanding blood vessels in and around the anus, which helps to increase the blood supply to the fissure, helping it heal faster.

It can also help reduce the pressure in your anal canal, which should help ease the pain.

The majority of acute fissures, which are present for less than six weeks, will heal with GTN treatment. Around 7 in every 10 chronic fissures heal with GTN therapy if used correctly.

Headaches are a very common side effect of this type of GTM ointment, affecting up to half of people using it.

Some people may also feel dizzy or lightheaded after using GTN. It isn't suitable for children and should be used with caution in women who are pregnant or breastfeeding.

If headaches are a problem, reducing the ointment dosage for a few days can help. Using only a pea-sized amount of ointment five or six times a day is often better than using a larger amount twice a day.

Make sure you apply the ointment to the skin around the anus and don't push it inside the anal canal.

You'll usually have to use GTN ointment for at least six weeks, or until your fissure has completely healed.

Topical anaesthetics

If you have particularly severe anal pain, your GP may prescribe a topical anaesthetic to numb your anus before passing stools.

A topical medicine is one you apply directly to the affected area. It won't help fissures heal, but it can help ease the pain.

Lidocaine is the most commonly prescribed topical anaesthetic for anal fissures. It comes in the form of either a gel or an ointment, and is usually only used for one to two weeks because the fissure should start to heal within this time.

Calcium channel blockers

Calcium channel blockers, such as diltiazem, are a type of medication usually used to treat high blood pressure (hypertension).

However,topical calcium channel blockers that are applied directly to the anus have also proved useful in treating somepeople with anal fissures.

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

Side effects can include headaches, dizziness, and itchiness or burning at the site when you apply the medication. Any side effects should pass within a few days once your body gets used to the medication.

Topical calcium channel blockers are thought to be about as effective as GTN ointment for treating anal fissures, and may be recommended if other medications haven't helped.

As with GTN ointment, you'll usually have to use calcium channel blockers for at least six weeks, or until your fissure has completely healed.

Botulinum toxin injections

Botulinum toxinis a relatively new treatment for anal fissures. It's usually used if other medications haven't helped. Botulinum toxin is a powerful poison that's safe to use in small doses.

If you have an anal fissure, an injection of the toxin can be used to paralyse your sphincter muscle. This should prevent the muscle from spasming, helping reduce pain and allowing the fissure to heal.

It's not clear exactly how effective botulinum toxin injections are for anal fissures, but research suggests they're helpful formore thanhalf the people who have them. This is similar to having treatment with GTN ointment and topical calcium channel blockers.

The effects ofbotulinum toxin injections last for around two to three months, which should normally allow enough time for the fissure to heal.

Follow-up

You may have a follow-up appointment a few weeks after starting your treatment. This will allow your GP to check your fissure has healed or is showing adequate signs of improvement.

If the fissure has completelyhealed,your GP may recommenda further follow-up appointment a few weeks later.

If your anal fissure is particularly severe or doesn't respond to treatment after eight weeks, you may have to be referred to a colorectal surgeon,a doctor who specialises in conditions that affect the rectum and anus,for specialist treatment. This usually involves having some type of surgery.

Surgery

Surgery may be recommended if other treatments haven't worked.

It is generally considered to be the most effective treatment for anal fissures, with more than 90% of people experiencing good long-term results. However, it does carry a small risk of complications.

There are a number of different surgical techniques that can be used to treat anal fissures. The main techniques used are outlined below.

Lateralsphincterotomy

A lateralsphincterotomy involvesmaking a small cut inthe ring of muscle surrounding the anal canal (sphincter) to help reduce the tension in your anal canal. This allows the anal fissure to heal and reduces your chances of developing any more fissures.

Itis a short and relatively straight forward operation that's usually carried out under a general anaesthetic on a day patient basis. This means you'll be asleep while the procedure is carried out, butyou won't usually have to spend the night in hospital.

A lateralsphincterotomy is one of the most effective treatments for anal fissures, with a good track record of success.Most people will fully heal within two to four weeks.

Less than 1 in 20 people who have this type of surgery will experience some temporary loss of bowelcontrol (bowel incontinence) afterwards as a result of damage to the anal muscles.

However, this is usually a mild type of incontinence where the person is unable to prevent passing wind, and usually only lasts a few weeks.

Advancement anal flaps

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

This procedure may be recommended to treat long-term (chronic) anal fissures caused by pregnancy or an injury to the anal canal.