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Research ArticleTools for Practice

Topical treatments for anal fissure

Callie Fagan, Michael R. Kolber and Adrienne J. Lindblad
Canadian Family Physician January 2023, 69 (1) 33; DOI: https://doi.org/10.46747/cfp.690133
Callie Fagan
Pharmacist at Calgary Co-op in Alberta.
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Michael R. Kolber
Professor in the Department of Family Medicine at the University of Alberta in Edmonton.
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Adrienne J. Lindblad
Clinical Evidence Expert Lead for the College of Family Physicians of Canada and Associate Clinical Professor in the Department of Family Medicine at the University of Alberta.
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Clinical question

How effective are topical treatments (calcium channel blockers [CCBs], nitrates, and vitamin E) for chronic anal fissures in adults?

Bottom line

Healing rates with topical nitroglycerin are roughly 60% versus 40% with placebo at 8 weeks. Topical CCBs are at least as good as nitroglycerin, with a lower risk of headache (7% versus 56%). Based on 1 RCT, topical vitamin E may be superior to nitroglycerin (86% versus 66% healed at 8 weeks).

Evidence

Five meta-analyses of RCTs from the past 10 years were identified.1-5 Adjunctive treatments were usually unclear (often fibre therapy or dietary advice). Healing was defined based on examination findings or patient report. Results were statistically significant unless indicated.

  • Calcium channel blockers (eg, 2% diltiazem ointment): In 3 systematic reviews (1 to 7 RCTs, 60 to 727 patients), at about 6 weeks, 78% to 82% of patients were healed with CCBs versus 33% to 42% with control; number needed to treat (NNT)=3 (1 of the 3 analyses was not statistically different).1-3

  • Nitroglycerin (eg, nitroglycerin 0.2% to 0.4% ointment): In 17 RCTs (1063 patients), at 8 weeks,1 63% of patients were healed versus 38% placebo; NNT=4.

    • - Other systematic reviews found efficacy to be about 50% versus 35% placebo.2,3

  • Calcium channel blockers versus nitroglycerin: In 11 RCTs (770 patients), at 8 weeks, 79% of patients were healed with CCBs versus 65% with nitroglycerin.1 Similar results were found in other systematic reviews3-5 but were statistically different in only 1.3

    • - In 10 RCTs (590 patients), 7% had headache with CCBs versus 56% with nitroglycerin.1

  • Vitamin E: In 1 RCT (160 patients, twice daily treatment),6 at 8 weeks, 86% were healed with vitamin E versus 66% with nitroglycerin; NNT=5. None stopped vitamin E owing to headache versus 18% with nitroglycerin.

  • Limitations: Some reviews included pediatric populations or did not include all RCTs. Many RCTs were unblinded, underdosed nitroglycerin, or had unclear vitamin E doses.

Context

  • Guidelines recommend topical CCBs.7 Botulinum toxin injections and surgery are options for treatment failure, but fecal incontinence is possible.7

  • For an 8-week treatment, compounded topical CCBs or nitroglycerin cost roughly $60 per 30 g (personal communication from Stacy Jardine, Clinical Pharmacist, Peace River Value Drug Mart in Peace River, Alberta; 2022). Commercially available vitamin E ointment costs about $10 per 50 g.8

Implementation

Anal fissures are commonly found in middle-aged adults and in children.9 They are primarily diagnosed by clinicians, with symptoms including pain during or after passage of stool, rectal bleeding, and linear tear (with or without a sentinel tag).10 Most fissures are at the midline. Fissures not in the midline should be investigated for secondary causes (eg, Crohn disease).11 Differential diagnosis of severe anal pain includes fissure, thrombosed hemorrhoids, or perirectal abscess.9 Rectal bleeding is not necessarily diagnostic of malignancy but requires assessment and consideration of other risks factors.12

Notes

Tools for Practice articles in CFP are adapted from peer-reviewed articles at http://www.toolsforpractice.ca and summarize practice-changing medical evidence for primary care. Coordinated by Dr G. Michael Allan and Dr Adrienne J. Lindblad, articles are developed by the Patients, Experience, Evidence, Research (PEER) team and supported by the College of Family Physicians of Canada and its Alberta, Ontario, and Saskatchewan Chapters. Feedback is welcome at toolsforpractice{at}cfpc.ca.

Footnotes

  • Competing interests

    None declared

  • Copyright © 2023 the College of Family Physicians of Canada

References

  1. 1.↵
    1. Jin JZ,
    2. Hardy MO,
    3. Unasa H,
    4. Mauiliu-Wallis M,
    5. Weston M,
    6. Connolly A, et al.
    A systematic review and meta-analysis of the efficacy of topical sphincterotomy treatments for anal fissure. Int J Colorectal Dis 2022;37(1):1-15. Epub 2021 Oct 4.
    OpenUrl
  2. 2.↵
    1. Nelson RL,
    2. Thomas K,
    3. Morgan J,
    4. Jones A.
    Non surgical therapy for anal fissure. Cochrane Database Syst Rev 2012;(2):CD003431.
  3. 3.↵
    1. Nelson RL,
    2. Manuel D,
    3. Gumienny C,
    4. Spencer B,
    5. Patel K,
    6. Schmitt K, et al.
    A systematic review and meta-analysis of the treatment of anal fissure. Tech Coloproctol 2017;21(8):605-25. Epub 2017 Aug 9.
    OpenUrlCrossRefPubMed
  4. 4.
    1. Nevins EJ,
    2. Kanakala V.
    Topical diltiazem and glyceryl-trinitrate for chronic anal fissure: a meta-analysis of randomised controlled trials. Turk J Surg 2020;36(4):347-52.
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. Sajid MS,
    2. Whitehouse PA,
    3. Sains P,
    4. Baig MK.
    Systematic review of the use of topical diltiazem compared with glyceryltrinitrate for the nonoperative management of chronic anal fissure. Colorectal Dis 2013;15(1):19-26.
    OpenUrl
  6. 6.↵
    1. Ruiz-Tovar J,
    2. Llavero C.
    Perianal application of glyceryl trinitrate ointment versus tocopherol acetate ointment in the treatment of chronic anal fissure: a randomized clinical trial. Dis Colon Rectum 2022;65(3):406-12.
    OpenUrl
  7. 7.↵
    1. Wald A,
    2. Bharucha AE,
    3. Limketkai B,
    4. Malcolm A,
    5. Remes-Troche JM,
    6. Whitehead WE, et al.
    ACG clinical guidelines: management of benign anorectal disorders. Am J Gastroenterol 2021;116(10):1987-2008.
    OpenUrl
  8. 8.↵
    Webber vitamin E first aid ointment. Mississauga, ON: Walmart.ca; 2022. Available from: https://www.walmart.ca/en/ip/webber-vitamin-e-first-aid-ointment/6000189067438. Accessed 2022 Oct 7.
  9. 9.↵
    1. Lu Y,
    2. Kwaan MR,
    3. Lin AY.
    Diagnosis and treatment of anal fissures in 2021. JAMA 2021;325(7):688-9.
    OpenUrl
  10. 10.↵
    1. Dykstra MA,
    2. Buie WD.
    Anal fissures. CMAJ 2019;191(26):E737.
    OpenUrlFREE Full Text
  11. 11.↵
    1. Gilani A,
    2. Tierney G.
    Chronic anal fissure in adults. BMJ 2022;376:e066834.
    OpenUrlFREE Full Text
  12. 12.↵
    1. Del Giudice ME,
    2. Vella ET,
    3. Hey A,
    4. Simunovic M,
    5. Harris W,
    6. Levitt C.
    Systematic review of clinical features of suspected colorectal cancer in primary care. Can Fam Physician 2014;60:e405-15. Available from: https://www.cfp.ca/content/cfp/60/8/e405.full.pdf. Accessed 2022 Dec 9.
    OpenUrlAbstract/FREE Full Text
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Canadian Family Physician: 69 (1)
Canadian Family Physician
Vol. 69, Issue 1
1 Jan 2023
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Topical treatments for anal fissure
Callie Fagan, Michael R. Kolber, Adrienne J. Lindblad
Canadian Family Physician Jan 2023, 69 (1) 33; DOI: 10.46747/cfp.690133

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Callie Fagan, Michael R. Kolber, Adrienne J. Lindblad
Canadian Family Physician Jan 2023, 69 (1) 33; DOI: 10.46747/cfp.690133
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