Anal fissure

Conservative self-help measures can treat successfully approximately 80% of patients. Use of stool softeners and simple analgesia may also help.

Apply 1 to 2ml, 20-30min before opening bowels, when required. Avoid long-term use.

Apply twice daily until pain stops. Max. duration of use 8 weeks, apply to the anal canal, using 2% topical preparation.

Prescribing Notes:

The management of anal fissures requires stool softening; the aim is to pass stools of a soft, “toothpaste-like” consistency.
Anusol-HC can be used to provide symptomatic relief of anal fissure; it can be bought over-the-counter as Anusol Plus HC.
Lidocaine 5% ointment may be prescribed as a short course for pain for use before passing stools.
If the anal fissure does not heal with the above measures, then topical Diltiazem Hydrochloride can be used. If it still fails to settle afterwards, hospital referral should be considered.
Topical Diltiazem works by relaxing the anal sphincter, increasing the blood supply to the fissure, and thereby aiding healing. A small (pea sized) amount should be applied to the finger and placed at the entrance to the anus. It should be used twice a day every day for 2 months. It is important to complete the full course to offer the best chance of successful healing. Two tubes of the cream (2 x 30gm) should be prescribed as these should last approximately 2 months. Patient must be reviewed after this. A second course of Diltiazem can be prescribed if the anal fissure has not completely healed after the first.
Diltiazem is usually well tolerated but potential side effects include headaches, dizziness and itchiness or burning at the site when you use the cream. Most side effects will pass within a few days.
Glyceryl trinitrate 0.4% ointment (Rectogesic) is the only licensed product available for treatment of anal fissures but it has been classed as ‘Not recommended’ by SMC.

History Notes

27/10/2022

Addition of topical lidocaine, revised order of choices and update of prescribing notes ERWG Sept 22.

15/12/2021

East Region Formulary content agreed.

Conservative self-help measures can treat successfully approximately 80% of patients. Use of stool softeners and simple analgesia may also help. Seek specialist advice before prescribing topical preparations.

For dose, refer to BNF for Children.

By rectum using ointment.
Child 12-17 years. Apply sparingly twice daily for no longer than 7 days, to be applied morning and night, an additional dose should be applied after a bowel movement.

As per specialist.

Prescribing Notes:

The management of anal fissures requires stool softening; the aim is to pass stools of a soft, “toothpaste-like” consistency. Treatment of constipation will resolve symptoms in most paediatric patients.
Anusol-HC can be used to provide symptomatic relief of anal fissure.
Lidocaine 5% ointment may be prescribed as a short course for pain for use before passing stools.
If the anal fissure does not heal with the above measures, then alternative options including topical Diltiazem Hydrochloride may be considered for use by a specialist paediatric gastroenterologist or paediatric surgeon.
Topical Diltiazem works by relaxing the anal sphincter, increasing the blood supply to the fissure, and thereby aiding healing. Diltiazem is usually well tolerated but potential side effects include headaches, dizziness and itchiness or burning at the site when you use the cream. Most side effects will pass within a few days.

History Notes

30/08/2023

East Region Formulary content agreed - ERFC 09/08/2023.