Pearls of Wisdom: Refractory Anal Fissures
Marco is a 32-year-old physician who complains of painful rectal fissure. He has already tried a variety of standard treatments, including Sitz baths, topical steroids, and regulation of stool consistency with stool softeners.
We had previously suggested he try a topical 0.2% nitroglycerin ointment, but his anal fissure remain refractory.
What would you recommend next?
A. Nitroglycerin 2% ointment
B. Nifedipine 0.3% cream
C. Surgical anoplasty
D. Prednisone 30 mg/d PO for 6 weeks
Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. His “Pearls of Wisdom” as we like to call them, have been shared with primary care physicians annually in an educational presentation entitled 5TIWIKLY (“5 Things I Wish I Knew Last Year”…. or the grammatically correct, “5 Things I Wish I’d Known Last Year”).
Now, for the first time, Dr Kuritzky is sharing with the Consultant360 audience. Sign up today to receive new advice each week.
Answer: Nifedipine 0.3% cream
We have only recently become more informed on the etiology and potential management of anal fissures. Our earliest premises about anal fissure suspected simple rectal trauma from difficult stool passage as the etiology, but it was never clear why anal fissure was sometimes refractory to healing. Based on the observation that anal pressure was markedly elevated in persons with refractory anal fissure, investigators suspected that reducing anal pressure might allow healing.
Clinical trials with nitroglycerin (NTG) ointment 0.2% (see Pearls of Wisdom: Anal Fissures, May 7, 2014, Consultant360) were very favorable, healing the majority of otherwise refractory fissures. Nitroglycerin dramatically reduces anal pressure, which is theorized to enhance opportunity for healing.
Anorectal Complaints: Office Diagnosis and Treatment
Inflammatory Bowel Disease in a Nonagenarian
Our patient has tried standard measures, and even additional doses of NTG ointment, without success. Might there be another remedy worth trying?
Topical Nifedipine + Lidocaine Gel1
In a fairly large (n=110), prospective, randomized, double-blind trial, application of topical nifedipine cream 0.3% (with lidocaine) twice daily resulted in complete healing of anal fissure in about 95% of participants. In comparison, only 17% of participants reported similar results with topical hydrocortisone plus lidocaine. In the 6% of patients who did not respond, a second course of treatment had a 66% healing rate.
Topical Nifedipine + Lidocaine: Results1
What’s the “Take Home”?
The number of favorable responses among persons with otherwise refractory anal fissure to agents that lower intra-anal pressure is impressive. In particular, topical nifedipine cream has a remarkably high success rate, with no known serious toxicity.
1. Perrotti P, Bove A, Antropoli C, Molino D, et al. Topical nifedipine with lidocaine ointment vs active control for treatment of chronic anal fissure. Dis Colon Rectum. 2002;45(11):1468-1475.