Laxatives, including stool softeners, should be used as the initial management in all patients presenting with anal fissure. Short term use of topical local anaesthetics may be appropriate. If these measures are inadequate a topical preparation may be considered. For adults with confirmed chronic anal fissure glyceryl trinitrate (GTN) ointment 0.4% is an appropriate first choice topical therapy.

Glyceryl trinitrate

• Rectal ointment 0.4% (£39.30 = 30g)
• Rectal ointment 0.2% (unlicensed preparation) made by Torbay PMU, Paignton

Dose

• Apply 2.5cm of ointment to anal canal every 12 hours until pain stops; maximum duration of use 8 weeks

Notes

1. It is important not to confuse this with higher strength topical GTN preparations used in angina.
2. Patients should be advised that headache is a common dose-related side effect of GTN treatment.
3. It is often useful in the initial stages of treatment to combine GTN 0.4% ointment with a local anaesthetic and an osmotic laxative.
4. GTN 0.2% ointment is an unlicensed preparation which may be prescribed by secondary care consultants for the treatment of anal fissures in children.

Diltiazem

• Ointment 2% (unlicensed preparation) (£13.74 = 30g)
• Cream 2% (unlicensed preparation) (£12.48 = 30g)

Dose

• Apply twice daily for 8 weeks

Notes

1. Diltiazem cream/ointment is included as a treatment option for patients who have failed or are unable to tolerate GTN ointment
2. Unless contraindicated, diltiazem should be used as a second line treatment prior to consideration of botulinum toxin (see section 4.9.3 Drugs used in essential tremor, chorea, tics, and related disorders)
3. If there are no clinical factors to direct choice between the formulations of cream or ointment, the product of lowest acquisition cost should be prescribed