{ "slug": "sitz-baths-anal-fissure", "question": "Do sitz baths help an anal fissure heal?", "shortTitle": "Sitz Baths for Anal Fissure", "clinicalQuestion": "In adults with an acute or chronic anal fissure, do warm sitz baths improve healing, pain or recurrence compared with usual care or other treatments?", "pico": { "population": "Adults with an acute or chronic anal fissure", "intervention": "Warm sitz baths", "comparator": "Usual care, no sitz bath, or another treatment", "outcomes": [ "Fissure healing", "Pain score", "Recurrence", "Anal sphincter pressure" ] }, "category": "anorectal", "relatedConditions": [ "anal-fissure" ], "relatedTreatments": [], "relatedEvidence": [], "bottomLine": { "verdict": "It's unclear whether warm sitz baths speed up healing of an anal fissure beyond other conservative care — the trials that tested this directly don't agree with each other.", "detail": "Two small trials that added sitz baths on top of otherwise identical care found no significant difference in healing or pain, though one found higher patient satisfaction and another found less burning after surgery. A separate trial comparing a sitz-bath-plus-bran routine against topical ointments found a higher healing rate with the sitz-bath routine, but it wasn't tested against no sitz bath at all. No trial has compared sitz baths with doing nothing.", "studyIds": [ "pmid:16916391", "pmid:17534541", "pmid:3011180" ] }, "strength": { "level": "low", "why": "One well-conducted randomised trial addresses this question directly. The studies disagree with one another, so the overall certainty is lower than any single one of them.", "override": null }, "direction": { "level": "unclear", "why": "The studies point in different directions.", "override": null }, "counts": { "recordsRetrieved": 39, "recordsScreened": 39, "included": 23, "rcts": 9, "systematicReviews": 2, "observational": 3, "participants": 5836, "yearFrom": 1986, "yearTo": 2024, "registeredTrialsWithoutResults": 2 }, "excluded": [], "outcomes": [ { "name": "Fissure healing", "status": "insufficient", "note": "Results conflict. When sitz baths were added to otherwise identical care, healing was not significantly different. But a trial comparing a sitz-bath-based routine against topical ointments found a higher healing rate (87%) with the sitz-bath routine, and a systematic review found around 80% healing with sitz baths compared with higher healing from surgery.", "studyIds": [ "pmid:16916391", "pmid:3011180", "pmid:36337820" ] }, { "name": "Recurrence", "status": "not-studied", "note": "No study in this table measured whether fissures came back after healing with sitz baths.", "studyIds": [] }, { "name": "Anal sphincter pressure", "status": "not-studied", "note": "No study in this table measured anal sphincter pressure (muscle tightness around the anus) in relation to sitz baths.", "studyIds": [] } ], "benefits": [ { "text": "In one trial, people recovering from fissure surgery who used sitz baths reported significantly less anal burning after bowel movements, though overall pain scores were not different.", "studyIds": [ "pmid:17534541" ] }, { "text": "In one trial, patients reported higher satisfaction with sitz baths added to usual care, even though measured healing and pain scores were not significantly different.", "studyIds": [ "pmid:16916391" ] }, { "text": "A trial comparing a sitz-bath-plus-bran routine with topical ointments found a higher healing rate (87%) with the sitz-bath routine.", "studyIds": [ "pmid:3011180" ] }, { "text": "In the trials that tested sitz baths directly, no side effects were reported.", "studyIds": [ "pmid:36337820" ] } ], "limitations": [ { "text": "Most studies gave sitz baths to every patient in every group as part of standard background care, so they cannot show whether sitz baths themselves made any difference — the effect of sitz baths can't be separated from the other treatments given alongside them.", "studyIds": [ "pmid:39386341", "pmid:28629768", "pmid:28410787", "pmid:20676860", "pmid:20578418", "pmid:15521346", "pmid:12402050", "pmid:10626860" ] }, { "text": "Only a couple of trials isolated sitz baths by comparing a sitz-bath group with a no-sitz-bath group while keeping everything else the same, and these were small (46–58 people) and low quality.", "studyIds": [ "pmid:16916391", "pmid:17534541" ] }, { "text": "The trials that do address this question directly disagree with each other, which is the main reason certainty is low.", "studyIds": [ "pmid:16916391", "pmid:3011180", "pmid:17534541" ] }, { "text": "Several of the sources included are general review articles that simply restate sitz baths as standard first-line care without reporting any actual study data or numbers.", "studyIds": [ "pmid:38316476", "pmid:32920798", "pmid:26929749", "pmid:22534276", "pmid:21066990", "pmid:15881700", "pmid:8921768" ] }, { "text": "A large Cochrane review included sitz baths among dozens of compared treatments across 75 trials, but its abstract does not separate out a specific result for sitz baths alone.", "studyIds": [ "pmid:22336789" ] } ], "risks": [ { "text": "No side effects from sitz baths were reported in the studies that tested them directly.", "studyIds": [ "pmid:36337820" ], "severity": "minor" } ], "whyPeopleTryIt": [ { "text": "Warm water soaks feel soothing on painful, irritated skin around the anus." }, { "text": "Doctors commonly suggest sitz baths as a simple first step before trying medicines or surgery." }, { "text": "It's cheap, easy to do at home, and has a long-standing reputation as a home remedy." }, { "text": "People want to avoid stronger medication or surgery if they can." } ], "keyStudies": [ "pmid:3011180", "pmid:16916391", "pmid:17534541", "pmid:20580349", "pmid:36337820", "pmid:22336789", "pmid:20676860" ], "studies": [ { "id": "pmid:39386341", "pmid": "39386341", "doi": "10.34172/mejdd.2024.383", "nctId": null, "pmcid": "PMC11459288", "title": "Comparative Evaluation of Effects of Oral Diltiazem and Topical Diltiazem (2%) Ointment in the Treatment of Chronic Anal Fissure: A Prospective Randomized Study", "firstAuthor": "Sharma", "multipleAuthors": true, "journal": "Middle East J Dig Dis", "year": 2024, "design": "rct", "n": 50, "nField": "reported", "population": "adults with chronic anal fissure", "intervention": "oral diltiazem (plus sitz bath and stool softeners)", "comparator": "topical 2% diltiazem ointment (plus sitz bath and stool softeners)", "primaryOutcome": "pain relief and fissure healing after treatment", "result": "topical ointment gave better pain relief at 1 week, no difference in pain at 6 weeks, but better fissure healing with topical ointment at 6 weeks", "resultDirection": "mixed", "quality": "low", "qualityWhy": "Small group sizes (25 per arm) and no detail on blinding make the comparison hard to rely on.", "directness": "indirect", "limitations": "Small sample size; abstract does not describe blinding or how randomization was done; sitz bath was used as a background conservative measure in both groups rather than being the treatment under study.", "followUp": "6 weeks", "plainFinding": "Compared diltiazem forms, not sitz baths alone.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39386341/", "sourceText": "BACKGROUND: Fissure-in-Ano is a common condition of the anorectal region. Most of the time, it is managed non-surgically. There are various drugs used for the treatment of anal fissures. Calcium channel blockers are one of them that reduce the tone of sphincter muscles. The present study compares the efficacy of oral diltiazem and topical 2% diltiazem ointment in patients with chronic anal fissures. METHODS: Patients were randomized into two groups. Group A (n=25) received treatment in the form of oral diltiazem, while group B (n=25) received treatment in the form of 2% (weight/volume) diltiazem ointment for local application in addition to other conservative methods like sitz bath and stool softeners. Outcomes in the form of success of treatment and complications were assessed. Statistical analysis was done using MedCalc software version 14.0. P value of<0.05 was considered significant. RESULTS: The mean age of patients was 32.00±10.67 years in group A and 30.64±9.53 years in group B. Pain relief was significantly better in group B than in group A at the end of the first week (P=0.00018), but at the end of 6th week, no significant difference was observed. Fissure healing was more significant in group B than in group A after 6 weeks (P=0.0152). CONCLUSION: Local diltiazem ointment is a better option than oral diltiazem for anal fissures with respect to better outcomes and lesser complications.", "provenance": [ { "field": "n", "quote": "Group A (n=25) received treatment in the form of oral diltiazem, while group B (n=25) received treatment" }, { "field": "population", "quote": "patients with chronic anal fissures" }, { "field": "intervention", "quote": "oral diltiazem" }, { "field": "comparator", "quote": "2% (weight/volume) diltiazem ointment for local application in addition to other conservative methods like sitz bath and stool softeners" }, { "field": "primaryOutcome", "quote": "Pain relief was significantly better in group B than in group A at the end of the first week" }, { "field": "result", "quote": "Pain relief was significantly better in group B than in group A at the end of the first week (P=0.00018), but at the end of 6th week, no significant difference was observed. Fissure healing was more significant in group B than in group A after 6 weeks (P=0.0152)." } ] }, { "id": "pmid:38316476", "pmid": "38316476", "doi": "10.31128/AJGP/05-23-6843", "nctId": null, "pmcid": null, "title": "Anal fissures: An update on treatment options", "firstAuthor": "Lyle", "multipleAuthors": true, "journal": "Aust J Gen Pract", "year": 2024, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with anal fissures", "intervention": "sitz baths (warm water soaks) plus dietary fibre", "comparator": "no comparator described", "primaryOutcome": "fissure healing/treatment success", "result": "Abstract states sitz baths are part of first-line conservative therapy for acute anal fissure, but does not report outcome data", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a general narrative review summarising guidelines and does not present any original data or outcome results for sitz baths.", "directness": "direct", "limitations": "No study data, outcomes, or effect sizes are reported for sitz baths specifically; this is a general overview article.", "followUp": "", "plainFinding": "No evidence reported either way.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38316476/", "sourceText": "BACKGROUND: Anal fissure (AF) is the second most common anorectal complaint in healthcare settings. The presentation might be acute or chronic, characterised by severe pain with defaecation that persists for one to two hours. Non-surgical and surgical interventions are available based on the severity and persistence of the fissure. OBJECTIVE: The aim of this article is to review the pathophysiology, clinical presentation and management of AF under current guidelines. DISCUSSION: The aetiology of AF is unclear, although it is commonly associated with local trauma or associated chronic conditions. Acute AF is first treated with conservative therapy, including dietary fibre and sitz baths. Addition of topical nitrates, topical calcium channel blockers or botulinum toxin injection is indicated with failure of conservative treatment or at medical discretion. Surgical options are considered if AF persists despite treatment. Most present as hypertonic, but special consideration is needed for hypotonic or secondary presentations.", "provenance": [ { "field": "population", "quote": "Anal fissure (AF) is the second most common anorectal complaint in healthcare settings." }, { "field": "intervention", "quote": "Acute AF is first treated with conservative therapy, including dietary fibre and sitz baths." }, { "field": "comparator", "quote": "Addition of topical nitrates, topical calcium channel blockers or botulinum toxin injection is indicated with failure of conservative treatment or at medical discretion." }, { "field": "primaryOutcome", "quote": "Surgical options are considered if AF persists despite treatment." }, { "field": "result", "quote": "Acute AF is first treated with conservative therapy, including dietary fibre and sitz baths." } ] }, { "id": "pmid:36337820", "pmid": "36337820", "doi": "10.7759/cureus.30847", "nctId": null, "pmcid": "PMC9622030", "title": "The Efficacy of Sitz Baths as Compared to Lateral Internal Sphincterotomy in Patients with Anal Fissures: A Systematic Review", "firstAuthor": "Alnasser", "multipleAuthors": true, "journal": "Cureus", "year": 2022, "design": "systematic-review", "n": 11, "nField": "reported", "population": "people with anal fissures", "intervention": "sitz baths", "comparator": "lateral internal sphincterotomy (a surgical cut to the anal muscle)", "primaryOutcome": "healing, pain relief, and side effects from sitz baths", "result": "sitz baths helped healing (around 80% recovery) and pain relief with no reported side effects, but lateral internal sphincterotomy had higher healing rates", "resultDirection": "mixed", "quality": "low", "qualityWhy": "The review combines findings from many different studies without statistical pooling, so its conclusions are descriptive rather than rigorously quantified.", "directness": "direct", "limitations": "A quality assessment reduced 551 screened articles to only 11 included studies, and evidence on pain relief was described as conflicting.", "followUp": "", "plainFinding": "Helps healing but surgery heals more.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36337820/", "sourceText": "An anal fissure is a common condition that affects patients of all ages. Its clinical presentation is a sharp pain on defecation with or without blood. It is treated by conservative or surgical means. This study aims to assess the efficacy of a sitz bath as compared to lateral internal sphincterotomy in the treatment of anal fissures. The search strategy used keywords related to the topic of study. Three databases were used: PubMed, Google Scholar, and Science Direct. A total of 551 articles were screened. A quality assessment check was done on the articles leaving 11 articles. Four aspects of sitz bath outcomes were evaluated in the articles. In terms of analgesia, articles showed conflicting evidence. However, the overall evidence supports the use of sitz baths for their analgesic properties. In terms of healing, most articles had similar recovery rates of around 80%. Much of the research supported the use of sitz baths as the primary treatment to heal acute fissures. When compared to lateral internal sphincterotomy, the recovery rates of lateral internal sphincterotomy are superior to those of conservative treatment, including sitz baths. However, studies showed incontinence as a side effect of lateral internal sphincterotomy, and no studies reported side effects from the sitz baths. To conclude, the results of the articles support the use of sitz baths to treat anal fissures. Sitz baths have been found to have analgesic properties, as well as a good healing time. But, compared to lateral internal sphincterotomy, there is a significant difference in the healing rate at the end stage of treatment, lateral internal sphincterotomy is found to be superior. With regards to the side effects, none have been reported from using a sitz bath.", "provenance": [ { "field": "n", "quote": "leaving 11 articles" }, { "field": "population", "quote": "An anal fissure is a common condition that affects patients of all ages." }, { "field": "intervention", "quote": "a sitz bath" }, { "field": "comparator", "quote": "lateral internal sphincterotomy" }, { "field": "primaryOutcome", "quote": "Four aspects of sitz bath outcomes were evaluated in the articles." }, { "field": "result", "quote": "most articles had similar recovery rates of around 80%" }, { "field": "result", "quote": "the recovery rates of lateral internal sphincterotomy are superior to those of conservative treatment, including sitz baths" }, { "field": "result", "quote": "no studies reported side effects from the sitz baths" } ] }, { "id": "pmid:34212031", "pmid": "34212031", "doi": "10.1155/2021/5526644", "nctId": null, "pmcid": "PMC8208854", "title": "Anti-Inflammatory Activity and Quality Control of Erysimum cheiri (L.) Crantz", "firstAuthor": "Mosleh", "multipleAuthors": true, "journal": "Biomed Res Int", "year": 2021, "design": "lab", "n": null, "nField": "not-reported", "population": "not a patient population — in vitro laboratory study of wallflower (Erysimum cheiri) plant extracts", "intervention": "wallflower plant extracts (root, flower, aerial parts, seed) tested for anti-inflammatory activity in vitro", "comparator": "diclofenac sodium (anti-inflammatory drug) as reference comparator in lab assay", "primaryOutcome": "anti-inflammatory activity measured by albumin denaturation assay, plus plant quality control characteristics", "result": "Wallflower extracts showed strong anti-inflammatory activity in a lab test compared to diclofenac sodium, with root and flower extracts most potent", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is an in vitro lab study of plant extracts with no human participants and no anal fissure patients, so it cannot show whether sitz baths help fissures heal.", "directness": "indirect", "limitations": "In vitro albumin denaturation assay only; no human trial; anal fissure is only mentioned as a traditional use context, not tested; no sitz bath intervention was actually studied.", "followUp": "", "plainFinding": "No human fissure data; lab-only study.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/34212031/", "sourceText": "Wallflower (Erysimum cheiri) is employed as a popular herbal drug in traditional Persian medicine. Topical formulations including cerates, lotions, sitz baths, and poultices for inflammatory disorders such as arthritis, anal fissure, endometriosis, and mastitis are known. However, there is no monograph in current pharmacopoeia for the wallflower drug. The present study is aimed to screen in vitro anti-inflammatory activity of wallflower and perform quality control and characterization tests for different organs of the herb. In this regard, albumin denaturation activity, macroscopic and microscopic, phytochemical, HPTLC, and FT-IR characteristics were investigated. Wallflower showed strong anti-inflammatory activity compared to diclofenac sodium. The root (1.25, 2.5, and 5 mg/mL) and flower (10 mg/mL) extract exhibited higher anti-inflammatory activities than that of other plant organs at the same concentrations. Moreover, total ash was found higher in aerial parts (21.52 ± 0.06%) than flower (11.01 ± 0.03%), root (5.03 ± 0.03%), and seed (6.95 ± 0.06%), while water-soluble ash was higher in seed (34.89 ± 0.26%) than flower (5.00 ± 0.03%), aerial parts (7.16 ± 0.06%), and root (5.04 ± 0.01%). Acid-insoluble ash and sulphated ash were higher in root (9.50 ± 0.04%) and aerial part (28.37 ± 0.57%), respectively. In addition, loss on drying was ranged from 2.20 ± 0.20% in flowers to 6.00 ± 0.10% in aerial parts. On the other hand, HPTLC analysis verified cardenolide compounds in all organs of the herb, and quercetin was detected in the flavonoid fingerprint of acid hydrolysed flowers. According to FT-IR results, the observed spectral region at ~3500 cm-1 attributed to -OH stretching vibration. Also, C-H (~2900-2950 cm-1), isothiocyanate (~2340 cm-1), -C=O (~1740 cm-1), conjugated C=C of the aromatic ring (~1650 cm-1), and structure of the aromatic group (~1200-1000 cm-1) were monitored. This work is the first study to the best of our knowledge, suggesting wallflower as a potential drug candidate with the basis for a monograph in addition to initial in vitro anti-inflammatory data.", "provenance": [ { "field": "population", "quote": "screen in vitro anti-inflammatory activity of wallflower and perform quality control and characterization tests for different organs of the herb" }, { "field": "intervention", "quote": "albumin denaturation activity, macroscopic and microscopic, phytochemical, HPTLC, and FT-IR characteristics were investigated" }, { "field": "comparator", "quote": "Wallflower showed strong anti-inflammatory activity compared to diclofenac sodium" }, { "field": "primaryOutcome", "quote": "The present study is aimed to screen in vitro anti-inflammatory activity of wallflower and perform quality control and characterization tests for different organs of the herb" }, { "field": "result", "quote": "Wallflower showed strong anti-inflammatory activity compared to diclofenac sodium. The root (1.25, 2.5, and 5 mg/mL) and flower (10 mg/mL) extract exhibited higher anti-inflammatory activities than that of other plant organs at the same concentrations." } ] }, { "id": "pmid:32920798", "pmid": "32920798", "doi": "10.1055/s-0040-1716723", "nctId": null, "pmcid": null, "title": "Anal Fissure in Children", "firstAuthor": "Patkova", "multipleAuthors": true, "journal": "Eur J Pediatr Surg", "year": 2020, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "children with anal fissure", "intervention": "sitz baths (as part of conservative management)", "comparator": "no specific comparator stated for sitz baths alone", "primaryOutcome": "healing of the anal fissure", "result": "abstract does not report specific results or data for sitz baths; only states they are recommended as part of first-choice conservative therapy", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a general narrative review that does not present original data, trial results, or a specific finding about sitz baths on their own.", "directness": "direct", "limitations": "abstract does not describe study methods, controls, or specific outcomes for sitz baths; it is a general review statement", "followUp": "", "plainFinding": "No specific result reported.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32920798/", "sourceText": "Anal fissure is a common clinical problem in children and is defined as a longitudinal tear in the anal canal. The typical presentation is painful defecation and rectal bleeding. The etiology of anal fissure is unknown, but passage of hard stools and increased internal anal sphincter pressure are considered important factors. The treatment is oriented to relieve the spasm of the internal anal sphincter, which prevents healing of the fissure. Conservative management with stool softeners, topical analgesics, and sitz baths is recommended as first-choice therapy. Surgical treatment has been replaced by nonoperative management as definitive therapy, which is associated with a marginally higher success rate than placebo. Most recent studies have focused on nonoperative treatment with glyceryl trinitrate, calcium channel blockers, or botulinum toxin injection treatment. There are a few controlled studies to compare the different nonoperative treatment options in children. Success rates vary between the studies, and there is no clear evidence about which is the optimal nonoperative treatment. A significant recurrence rate has been reported after nonoperative management of anal fissure. It is important to treat constipation to avoid recurrent tears in the anal canal.", "provenance": [ { "field": "population", "quote": "Anal fissure is a common clinical problem in children" }, { "field": "intervention", "quote": "Conservative management with stool softeners, topical analgesics, and sitz baths is recommended as first-choice therapy." }, { "field": "primaryOutcome", "quote": "prevents healing of the fissure" }, { "field": "result", "quote": "Conservative management with stool softeners, topical analgesics, and sitz baths is recommended as first-choice therapy." }, { "field": "comparator", "quote": "which is associated with a marginally higher success rate than placebo" } ] }, { "id": "pmid:28629768", "pmid": "28629768", "doi": "10.1016/j.ijsu.2017.06.044", "nctId": null, "pmcid": null, "title": "Does the duration of symptoms of anal fissure impact its response to conservative treatment? A prospective cohort study", "firstAuthor": "Emile", "multipleAuthors": true, "journal": "Int J Surg", "year": 2017, "design": "prospective-cohort", "n": 60, "nField": "reported", "population": "adults with acute or chronic anal fissure", "intervention": "combined conservative treatment including bulking agents, sitz baths, and topical glyceryl trinitrate (GTN) 0.2%", "comparator": "patients with acute fissure (shorter symptom duration) versus patients with chronic fissure (longer symptom duration)", "primaryOutcome": "fissure healing rate, pain score, and constipation score at 6 weeks", "result": "healing was significantly better in acute fissure (80%) than chronic fissure (40%), and healing rates fell from 100% in those with symptoms under one month to 33.3% in those with symptoms over six months", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this study combined sitz baths with bulking agents and GTN cream without a group that omitted sitz baths, so it cannot show what sitz baths alone contributed, and there was no untreated comparison group.", "directness": "indirect", "limitations": "no isolated sitz-bath arm, no untreated or placebo control group, small sample, and treatments were given together so individual contributions cannot be separated", "followUp": "6 weeks", "plainFinding": "Combined treatment helped; sitz-bath effect unclear", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28629768/", "sourceText": "BACKGROUND: Conservative treatment is the first line of treatment for anal fissure. The current study aimed to evaluate the impact of symptom duration on the response of anal fissure to conservative treatment. PATIENTS AND METHODS: This prospective study was conducted on sixty patients with acute or chronic anal fissure who were treated conservatively with bulking agents, Sitz baths, and topical glyceryl trinitrate (GTN) 0.2%. Pain and constipation were assessed prior to treatment and at 6 weeks after therapy using visual analogue scale (VAS) and Wexner constipation score. Adverse effects as headache and postural hypotension were also queried. RESULTS: The mean pre-treatment VAS for acute fissure was significantly higher than chronic fissure (8.8 ± 0.96 Vs 5.8 ± 1.12), also the post-treatment VAS for acute fissure was significantly lower at 6 weeks of treatment (0.47 ± 0.8 Vs 2.5 ± 1.3). The baseline Wexner constipation score was comparable in both groups; however, at six weeks of treatment it declined more significantly in patients with acute fissure. Patients with acute fissure achieved significantly better healing than chronic fissure (80% Vs 40%). Healing rates decreased from 100% in patients with symptoms < one month to 33.3% in patients with symptoms >6 months. CONCLUSION: Conservative treatment including topical GTN 0.2% significantly hastened healing and relieved pain and other symptoms of acute more than chronic anal fissure. Healing rates of anal fissure in response to conservative treatment showed remarkable decrease in proportion to the duration of complaint.", "provenance": [ { "field": "population", "quote": "sixty patients with acute or chronic anal fissure" }, { "field": "intervention", "quote": "treated conservatively with bulking agents, Sitz baths, and topical glyceryl trinitrate (GTN) 0.2%" }, { "field": "comparator", "quote": "The mean pre-treatment VAS for acute fissure was significantly higher than chronic fissure" }, { "field": "primaryOutcome", "quote": "Pain and constipation were assessed prior to treatment and at 6 weeks after therapy using visual analogue scale (VAS) and Wexner constipation score" }, { "field": "result", "quote": "Patients with acute fissure achieved significantly better healing than chronic fissure (80% Vs 40%). Healing rates decreased from 100% in patients with symptoms < one month to 33.3% in patients with symptoms >6 months." }, { "field": "n", "quote": "sixty patients with acute or chronic anal fissure" }, { "field": "followUp", "quote": "assessed prior to treatment and at 6 weeks after therapy" } ] }, { "id": "pmid:28410787", "pmid": "28410787", "doi": "10.1016/j.jpedsurg.2017.04.003", "nctId": null, "pmcid": null, "title": "Efficacy of nitroglycerine ointment in the treatment of pediatric anal fissure", "firstAuthor": "Joda", "multipleAuthors": true, "journal": "J Pediatr Surg", "year": 2017, "design": "rct", "n": 105, "nField": "reported", "population": "children with anal fissure, ages 4 months to 5 years", "intervention": "nitroglycerine ointment added to standard conservative care (sitz bath, stool softener, local anesthetic)", "comparator": "standard conservative care alone (sitz bath, stool softener, local anesthetic)", "primaryOutcome": "symptom relief and fissure healing", "result": "the nitroglycerine group had higher rates of symptom relief and fissure healing than the conservative-care-only group, differences were statistically significant", "resultDirection": "benefit", "quality": "low", "qualityWhy": "small, unequal-sized groups from a single hospital, and the study did not isolate sitz baths since both groups received them alongside other treatments.", "directness": "indirect", "limitations": "Unequal randomization (70 vs 35), single-center design, and sitz bath was part of background care in both arms rather than the tested variable.", "followUp": "8 weeks", "plainFinding": "Adding nitroglycerine helped more than usual care", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28410787/", "sourceText": "BACKGROUND: Anal fissure is the most common anal disease in children. In the past few decades, the understanding of its pathophysiology has led to a progressive reduction in invasive procedures in favor of conservative treatment based on stool softeners and the relaxation of the anal sphincter. This randomized controlled study assessed the safety and efficacy of nitroglycerine (NTG) ointment in the treatment of pediatric anal fissure, which had not yet been proved. PATIENTS AND METHODS: An unequal randomized controlled study included 105 pediatric patients with anal fissure who had presented to the private and outpatient clinics of the Central Teaching Hospital of Pediatrics during the period from February 2015 to May 2016. The control group consisted of 70 patients. Both groups were treated with classical conservative therapy of sitz bath, stool softener, and local anesthetic. In the second group, chemical sphincterotomy with 0.2% NTG ointment was used in 35 patients, and was applied at the anal canal twice daily for 8weeks. The primary outcomes of symptomatic improvement and healed fissure, as well as side effects, were analyzed. RESULTS: The average age of patients was 2years (range, 4months to 5years). Patients in the NTG group had 77% symptomatic relief and 60% healed fissure compared to the control group, which had 54% and 32.8% respectively. All were statistically significant. No serious adverse effects were noticed during the treatment period. CONCLUSION: The use of 0.2% NTG ointment is an effective therapy for anal fissure in children in terms of good healing rate and rapid symptom relief, but it has the drawback of a long treatment period, making patient compliance more difficult, in addition to the problems of tolerance and recurrence. TYPE OF STUDY: Prospective randomized controlled study (treatment study). LEVEL OF EVIDENCE: Type 2.", "provenance": [ { "field": "population", "quote": "The average age of patients was 2years (range, 4months to 5years)." }, { "field": "population", "quote": "105 pediatric patients with anal fissure" }, { "field": "intervention", "quote": "chemical sphincterotomy with 0.2% NTG ointment was used in 35 patients, and was applied at the anal canal twice daily for 8weeks" }, { "field": "comparator", "quote": "Both groups were treated with classical conservative therapy of sitz bath, stool softener, and local anesthetic." }, { "field": "primaryOutcome", "quote": "The primary outcomes of symptomatic improvement and healed fissure, as well as side effects, were analyzed." }, { "field": "result", "quote": "Patients in the NTG group had 77% symptomatic relief and 60% healed fissure compared to the control group, which had 54% and 32.8% respectively. All were statistically significant." }, { "field": "n", "quote": "included 105 pediatric patients with anal fissure" } ] }, { "id": "pmid:26929749", "pmid": "26929749", "doi": "10.1055/s-0035-1570390", "nctId": null, "pmcid": "PMC4755763", "title": "Anal Fissure", "firstAuthor": "Beaty", "multipleAuthors": true, "journal": "Clin Colon Rectal Surg", "year": 2016, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with anal fissures", "intervention": "sitz baths (along with high fiber diet and pharmacological agents)", "comparator": "", "primaryOutcome": "fissure healing", "result": "half of all patients with fissures healed with nonoperative management including sitz baths", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a general narrative review chapter, not a study testing sitz baths specifically, so it can't show whether sitz baths themselves caused healing.", "directness": "indirect", "limitations": "Sitz baths are mentioned only as one part of a bundle of nonoperative treatments; no separate data or comparison for sitz baths alone is given.", "followUp": "", "plainFinding": "Review mentions sitz baths, no specific data.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/26929749/", "sourceText": "Anal fissure (fissure-in-ano) is a very common anorectal condition. The exact etiology of this condition is debated; however, there is a clear association with elevated internal anal sphincter pressures. Though hard bowel movements are implicated in fissure etiology, they are not universally present in patients with anal fissures. Half of all patients with fissures heal with nonoperative management such as high fiber diet, sitz baths, and pharmacological agents. When nonoperative management fails, surgical treatment with lateral internal sphincterotomy has a high success rate. In this chapter, we will review the symptoms, pathophysiology, and management of anal fissures.", "provenance": [ { "field": "population", "quote": "Anal fissure (fissure-in-ano) is a very common anorectal condition." }, { "field": "intervention", "quote": "nonoperative management such as high fiber diet, sitz baths, and pharmacological agents" }, { "field": "primaryOutcome", "quote": "Half of all patients with fissures heal with nonoperative management" }, { "field": "result", "quote": "Half of all patients with fissures heal with nonoperative management such as high fiber diet, sitz baths, and pharmacological agents." } ] }, { "id": "pmid:22534276", "pmid": "22534276", "doi": null, "nctId": null, "pmcid": null, "title": "Evaluation and management of common anorectal conditions", "firstAuthor": "Fargo", "multipleAuthors": true, "journal": "Am Fam Physician", "year": 2012, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "patients with common anorectal conditions, including anal fissures", "intervention": "sitz baths", "comparator": "other treatments such as onabotulinumtoxinA, topical nitroglycerin, or topical calcium channel blockers", "primaryOutcome": "effective treatment for anal fissures", "result": "abstract lists onabotulinumtoxinA, topical nitroglycerin, and topical calcium channel blockers as effective treatments for anal fissures, but sitz baths are not mentioned for fissures — only for simple anorectal fistulas", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a general narrative review of anorectal conditions, not a study testing sitz baths for fissures, and it gives no original data on that specific question.", "directness": "indirect", "limitations": "the abstract does not evaluate sitz baths as a treatment for anal fissures specifically; it mentions sitz baths only in the context of simple anorectal fistulas, and does not report a study design, sample size, or outcome data for fissures and sitz baths.", "followUp": "", "plainFinding": "Not studied for fissures here.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/22534276/", "sourceText": "The prevalence of benign anorectal conditions in the primary care setting is high, although evidence of effective therapy is often lacking. In addition to recognizing common benign anorectal disorders, physicians must maintain a high index of suspicion for inflammatory and malignant disorders. Patients with red flags such as increased age, family history, persistent anorectal bleeding despite treatment, weight loss, or iron deficiency anemia should undergo colonoscopy. Pruritus ani, or perianal itching, is managed by treating the underlying cause, ensuring proper hygiene, and providing symptomatic relief with oral antihistamines, topical steroids, or topical capsaicin. Effective treatments for anal fissures include onabotulinumtoxinA, topical nitroglycerin, and topical calcium channel blockers. Symptomatic external hemorrhoids are managed with dietary modifications, topical steroids, and analgesics. Thrombosed hemorrhoids are best treated with hemorrhoidectomy if symptoms are present for less than 72 hours. Grades I through III internal hemorrhoids can be managed with rubber band ligation. For the treatment of grade III internal hemorrhoids, surgical hemorrhoidectomy has higher remission rates but increased pain and complication rates compared with rubber band ligation. Anorectal condylomas, or anogenital warts, are treated based on size and location, with office treatment consisting of topical trichloroacetic acid or podophyllin, cryotherapy, or laser treatment. Simple anorectal fistulas can be treated conservatively with sitz baths and analgesics, whereas complex or nonhealing fistulas may require surgery. Fecal impaction may be treated with polyethylene glycol, enemas, or manual disimpaction. Fecal incontinence is generally treated with loperamide and biofeedback. Surgical intervention is reserved for anal sphincter injury.", "provenance": [ { "field": "intervention", "quote": "Simple anorectal fistulas can be treated conservatively with sitz baths and analgesics" }, { "field": "result", "quote": "Effective treatments for anal fissures include onabotulinumtoxinA, topical nitroglycerin, and topical calcium channel blockers." }, { "field": "population", "quote": "The prevalence of benign anorectal conditions in the primary care setting is high" }, { "field": "comparator", "quote": "Effective treatments for anal fissures include onabotulinumtoxinA, topical nitroglycerin, and topical calcium channel blockers." }, { "field": "primaryOutcome", "quote": "Effective treatments for anal fissures include onabotulinumtoxinA, topical nitroglycerin, and topical calcium channel blockers." } ] }, { "id": "pmid:22336789", "pmid": "22336789", "doi": "10.1002/14651858.CD003431.pub3", "nctId": null, "pmcid": "PMC7173741", "title": "Non surgical therapy for anal fissure", "firstAuthor": "Nelson", "multipleAuthors": true, "journal": "Cochrane Database Syst Rev", "year": 2012, "design": "meta-analysis", "n": 5031, "nField": "reported", "population": "people with anal fissure (acute, chronic, and in children)", "intervention": "sitz baths", "comparator": "other non-surgical treatments, placebo, or surgery", "primaryOutcome": "whether the fissure healed", "result": "the abstract lists sitz baths as one of many agents compared across 75 trials but does not report a specific healing result for sitz baths alone", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "the review combines many different therapies and trials but gives no specific data, numbers, or comparison results for sitz baths on its own.", "directness": "indirect", "limitations": "the abstract does not separate out sitz bath results from the many other therapies studied, so no specific effect size or statistical comparison for sitz baths is given.", "followUp": "", "plainFinding": "No specific result reported.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/22336789/", "sourceText": "BACKGROUND: Because of the disability associated with surgery for anal fissure and the risk of incontinence, medical alternatives for surgery have been sought. Most recently, pharmacologic methods that relax the anal smooth muscle, to accomplish reversibly what occurs in surgery, have been used to obtain fissure healing. OBJECTIVES: To assess the efficacy and morbidity of various medical therapies for anal fissure. SEARCH METHODS: Search terms include \"anal fissure randomized\". Timing from 1966 to August 2010. Further details of the search below. SELECTION CRITERIA: Studies in which participants were randomized to a non-surgical therapy for anal fissure. Comparison groups may include an operative procedure, an alternate medical therapy or placebo. Chronic fissure, acute fissure and fissure in children are included in the review. Atypical fissures associated with inflammatory bowel disease or cancer or anal infection are excluded. DATA COLLECTION AND ANALYSIS: Data were abstracted from published reports and meeting abstracts, assessing method of randomization, blinding, \"intention to treat\" and drop-outs, therapies, supportive measures (applied to both groups), dosing and frequency and cross-overs. Dichotomous outcome measures included Non-healing of the fissure (a combination of persistence and recurrence), and Adverse events (including incontinence, headache, infection, anaphylaxis). Continuous outcome measures included measures of pain relief and anorectal manometry. MAIN RESULTS: In this update 23 studies including 1236 participants is added to the 54 studies and 3904 participants in the 2008 publication, however 2 studies were from the last version reclassified as un included, so the final number of participants is 5031.49 different comparisons of the ability of medical therapies to heal anal fissure have been reported in 75 RCTs. Seventeen agents were used (nitroglycerin ointment (GTN), isosorbide mono & dinitrate, Botulinum toxin (Botox), diltiazem, nifedipine (Calcium channel blockers or CCBs), hydrocortisone, lignocaine, bran, minoxidil, indoramin, clove oil, L-arginine, sitz baths, sildenafil, \"healer cream\" and placebo) as well as Sitz baths, anal dilators and surgical sphincterotomy. GTN was found to be marginally but significantly better than placebo in healing anal fissure (48.9% vs. 35.5%, p < 0.0009), but late recurrence of fissure was common, in the range of 50% of those initially cured. Botox and CCBs were equivalent to GTN in efficacy with fewer adverse events. No medical therapy came close to the efficacy of surgical sphincterotomy, though none of the medical therapies in these RCTs were associated with the risk of incontinence. AUTHORS' CONCLUSIONS: Medical therapy for chronic anal fissure, currently consisting of topical glyceryl trinitrate, botulinum toxin injection or the topical calcium channel blockers nifedipine or diltiazem in acute and chronic fissure and fissure in children may be applied with a chance of cure that is marginally better than placebo. For chronic fissure in adults all medical therapies are far less effective than surgery. A few of the newer agents investigated show promise based only upon single studies (clove oil, sildenifil and a \"healer cream\") but lack comparison to more established medications.", "provenance": [ { "field": "n", "quote": "so the final number of participants is 5031." }, { "field": "intervention", "quote": "Sitz baths" }, { "field": "population", "quote": "Chronic fissure, acute fissure and fissure in children are included in the review." }, { "field": "primaryOutcome", "quote": "Dichotomous outcome measures included Non-healing of the fissure (a combination of persistence and recurrence), and Adverse events" }, { "field": "comparator", "quote": "Comparison groups may include an operative procedure, an alternate medical therapy or placebo." }, { "field": "result", "quote": "Seventeen agents were used (nitroglycerin ointment (GTN), isosorbide mono & dinitrate, Botulinum toxin (Botox), diltiazem, nifedipine (Calcium channel blockers or CCBs), hydrocortisone, lignocaine, bran, minoxidil, indoramin, clove oil, L-arginine, sitz baths, sildenafil, \"healer cream\" and placebo) as well as Sitz baths, anal dilators and surgical sphincterotomy." } ] }, { "id": "pmid:21066990", "pmid": "21066990", "doi": "10.2298/aci1003083g", "nctId": null, "pmcid": null, "title": "Supportive therapies in ano-rectal diseases--are they really useful?", "firstAuthor": "Gupta", "multipleAuthors": false, "journal": "Acta Chir Iugosl", "year": 2010, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with common anal disorders such as hemorrhoids, anal fissure and fistula", "intervention": "supportive therapies such as sitz baths, local applications, and diet/lifestyle changes", "comparator": "no comparator specified", "primaryOutcome": "whether supportive therapies are beneficial", "result": "the paper discusses advantages and pitfalls but does not state a clear finding on effectiveness", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a narrative discussion paper without original data, trial results, or a systematic search, so it cannot show whether sitz baths work.", "directness": "indirect", "limitations": "No original data, no systematic methodology, and it covers fissures, hemorrhoids and fistula together rather than fissures alone.", "followUp": "", "plainFinding": "No clear answer given.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/21066990/", "sourceText": "Epidemiological features of proctological disease are not well known because available studies have provided variable conclusions. Risk factors frequently mentioned include heredity, high socioeconomic level, obesity, smoking, a diet rich in fats, alcohol, spices and pepper as well low fluid intake have all been implicated. While treating patients with various ano-rectal pathologies, apart from definitive treatment, various additional or supportive therapies are being advised both by the family physicians and surgeons. These include local applications, sitz baths, modification in the diet and life style. But are these supportive therapies really beneficial or they are just empirical? This paper elaborates the various supportive therapies advocated in the common anal disorders like hemorrhoids, anal fissure and fistula and summarizes the advantages and pitfalls of these treatment additives.", "provenance": [ { "field": "population", "quote": "various ano-rectal pathologies" }, { "field": "intervention", "quote": "local applications, sitz baths, modification in the diet and life style" }, { "field": "comparator", "quote": "But are these supportive therapies really beneficial or they are just empirical?" }, { "field": "primaryOutcome", "quote": "But are these supportive therapies really beneficial or they are just empirical?" }, { "field": "result", "quote": "summarizes the advantages and pitfalls of these treatment additives" } ] }, { "id": "pmid:20676860", "pmid": "20676860", "doi": "10.1007/s00595-009-4141-3", "nctId": null, "pmcid": null, "title": "Efficacy of lanolin and bovine type I collagen in the treatment of childhood anal fissures: a prospective, randomized, controlled clinical trial", "firstAuthor": "Büyükyavuz", "multipleAuthors": true, "journal": "Surg Today", "year": 2010, "design": "rct", "n": 71, "nField": "reported", "population": "children with acute anal fissure", "intervention": "topical lanolin ointment or bovine type I collagen spray, added on top of warm sitz baths, analgesic cream, and stool softeners", "comparator": "warm sitz baths, analgesic cream, and stool softeners alone (no added ointment)", "primaryOutcome": "complete healing of the anal fissure at 4 weeks", "result": "68% healed with sitz baths/analgesic/stool softener alone, versus 92.9% with added lanolin and 100% with added collagen; the difference was significant", "resultDirection": "benefit", "quality": "low", "qualityWhy": "small, open-label trial without blinding, so results could be biased and are hard to apply broadly.", "directness": "indirect", "limitations": "Open-labeled design (no blinding), small group sizes, and all groups also received sitz baths, so this trial does not isolate the effect of sitz baths alone.", "followUp": "4 weeks", "plainFinding": "Added lanolin or collagen healed more fissures than sitz baths alone.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/20676860/", "sourceText": "PURPOSE: We designed an open-labeled, prospective, randomized, controlled clinical trial to test the efficacy of topical lanolin ointment (PureLan) and bovine type I collagen spray (Gelfix) in the treatment of childhood anal fissures. METHODS: Seventy-one children with acute anal fissure were divided randomly into three groups: group I (control; n = 25), group II (PureLan; n = 28), and group III (Gelfix; n = 18). All children were assigned to have warm sitz baths, topical analgesic creams, and stool softeners. Patients in groups II and III were also treated with topical lanolin ointment and bovine type I collagen, respectively. All children were re-examined 4 weeks later. RESULTS: Complete healing of the anal fissure was observed in 68% of the group I patients, but in 92.9% and 100% of the group II and III patients, respectively. The difference among groups was significant in terms of complete fissure healing (P = 0.003), but the efficacy of topical lanolin ointment and bovine type I collagen spray did not differ significantly (P = 0.078). CONCLUSION: Our data suggest that topical lanolin ointment and bovine type I collagen spray are effective in the treatment of acute anal fissure in children.", "provenance": [ { "field": "n", "quote": "Seventy-one children with acute anal fissure were divided randomly into three groups" }, { "field": "population", "quote": "Seventy-one children with acute anal fissure" }, { "field": "intervention", "quote": "Patients in groups II and III were also treated with topical lanolin ointment and bovine type I collagen, respectively." }, { "field": "comparator", "quote": "All children were assigned to have warm sitz baths, topical analgesic creams, and stool softeners." }, { "field": "primaryOutcome", "quote": "Complete healing of the anal fissure was observed in 68% of the group I patients, but in 92.9% and 100% of the group II and III patients, respectively." }, { "field": "result", "quote": "The difference among groups was significant in terms of complete fissure healing (P = 0.003), but the efficacy of topical lanolin ointment and bovine type I collagen spray did not differ significantly (P = 0.078)." } ] }, { "id": "pmid:20580349", "pmid": "20580349", "doi": "10.1016/j.ciresp.2010.04.007", "nctId": null, "pmcid": null, "title": "[Cold or hot sitz baths in the emergency treatment of acute anal pain due to anorectal disease? Results of a randomised clinical trial]", "firstAuthor": "Maestre", "multipleAuthors": true, "journal": "Cir Esp", "year": 2010, "design": "rct", "n": 24, "nField": "reported", "population": "adults with acute anal pain from hemorrhoids or anal fissures", "intervention": "sitz baths with cold water (below 15°C)", "comparator": "sitz baths with hot water (above 30°C)", "primaryOutcome": "pain level and quality of life after 7 days", "result": "no significant difference in pain control between cold and hot sitz baths", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "very small study (24 patients) mixing hemorrhoid and fissure patients, looking at pain relief rather than fissure healing.", "directness": "indirect", "limitations": "Small sample size (only 24 randomised patients), combined hemorrhoid and fissure patients, and outcome measured was pain/quality of life rather than fissure healing.", "followUp": "7 days", "plainFinding": "No difference between hot and cold baths.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/20580349/", "sourceText": "INTRODUCTION: The popular belief advocates the use of sitz (sitting) baths with cold water for the treatment of acute anal pain, but clinical practice guides recommend the use of hot water for its known effect on the at-rest anal pressure. AIM: The objective of the study was to examine the analgesic effect on the quality of life, manometer data and clinical progress, of the two temperatures in sitz baths in patients with anal pain. MATERIAL AND METHODS: A randomised clinical trial on patients with acute anal pain due to haemorrhoids or anal fissures, divided into Group 1: Sitz baths with water at a temperature of less than 15 degrees C, and Group 2: Baths with a water temperature above 30 degrees C. The analgesia was the same in both groups. An analysis was made of the pain at 7 days (visual analogue scale), quality of life (SF-36), anal at-rest pressure and disease progress. RESULTS: Of the 27 eligible patients, 24 were randomised (Group 1: n=12 y Group 2: n=12). There were no statistical differences in pain, but it remained stable in Group 1, but gradually decreased in the patients of Group 2, the difference being in the pain scores on the first day compared to the seventh in Group 2 (p=0.244). The rest of the variables were similar. CONCLUSION: There were no statistically significant differences in pain control from day 1 to day 7 in the Group with sitz baths with hot water. (ISRCTN Number: 50105150).", "provenance": [ { "field": "n", "quote": "Of the 27 eligible patients, 24 were randomised (Group 1: n=12 y Group 2: n=12)." }, { "field": "population", "quote": "patients with acute anal pain due to haemorrhoids or anal fissures" }, { "field": "intervention", "quote": "Group 1: Sitz baths with water at a temperature of less than 15 degrees C" }, { "field": "comparator", "quote": "Group 2: Baths with a water temperature above 30 degrees C" }, { "field": "primaryOutcome", "quote": "An analysis was made of the pain at 7 days (visual analogue scale), quality of life (SF-36), anal at-rest pressure and disease progress." }, { "field": "result", "quote": "There were no statistical differences in pain, but it remained stable in Group 1, but gradually decreased in the patients of Group 2" } ] }, { "id": "pmid:20578418", "pmid": "20578418", "doi": null, "nctId": null, "pmcid": null, "title": "Botox for chronic anal fissure: is it useful? A clinical experience with mid-term follow-up", "firstAuthor": "Piccinni", "multipleAuthors": true, "journal": "Acta Biomed", "year": 2009, "design": "prospective-cohort", "n": 60, "nField": "reported", "population": "patients with chronic anal fissure", "intervention": "botulinum toxin injection combined with hygiene measures including sitz baths, Vaseline oil and water intake", "comparator": "no control group; outcomes compared before and after treatment only", "primaryOutcome": "healing of the anal fissure", "result": "29 of 60 patients (48.33%) healed after the first botulinum toxin injection; 20 more healed after a second injection, while 11 needed surgery", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This was a small, open-label study with no comparison group, so it cannot show whether sitz baths themselves helped healing.", "directness": "indirect", "limitations": "Non-comparative, open-label design; sitz baths were only one part of a combined hygiene regimen alongside the main treatment (botulinum toxin), so their individual effect cannot be determined.", "followUp": "24 months", "plainFinding": "No specific sitz bath data.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/20578418/", "sourceText": "BACKGROUND: Sphincterotomy has been the most commonly used treatment for chronic anal fissures. Although effective it is associated with incontinence (0-20%). Intrasphincteric Botulinum Toxin A injection seems to be a reliable option. The aim of this clinical report is to verify the effectiveness of this treatment in relieving symptoms and healing fissures without relapse. METHODS: The study design was an open label non-comparative prospective trial to evaluate the efficacy ofbotulinum toxin injection in anal sphincters. In the period 2003-2005 sixty patients were enrolled in our Unit of Coloproctology. After inoculation hygiene measures (sitz baths, Vaseline oil and water intake) were recommended. After the first 4 weeks without improvement we administered a second injection (30 U.I). After failure of the second administration the patient was addressed to surgery. Mean follow-up was 24 months; patients were re-evaluated at the 6th, 12th and 24th month. RESULTS: In 29 pts the fissure was healed (48.33%) after the first injection; 31 patients (51.6%) were re-treated; 20 pts presented a complete healing of the fissure in a period ranging between 4-5 weeks from the second injection and 11 patients were introduced to surgery. In 3 cases we observed haemorrhoidal thrombosis. Gas incontinence was reported in two patients and solved spontaneously. CONCLUSIONS: Our clinical experience suggests that botulinum toxin therapy can be considered effective and safe. It can be proposed to the patient as first line therapy before surgery.", "provenance": [ { "field": "n", "quote": "sixty patients were enrolled in our Unit of Coloproctology" }, { "field": "population", "quote": "chronic anal fissures" }, { "field": "intervention", "quote": "After inoculation hygiene measures (sitz baths, Vaseline oil and water intake) were recommended" }, { "field": "comparator", "quote": "The study design was an open label non-comparative prospective trial" }, { "field": "primaryOutcome", "quote": "to verify the effectiveness of this treatment in relieving symptoms and healing fissures without relapse" }, { "field": "result", "quote": "In 29 pts the fissure was healed (48.33%) after the first injection; 31 patients (51.6%) were re-treated; 20 pts presented a complete healing of the fissure" } ] }, { "id": "pmid:17534541", "pmid": "17534541", "doi": "10.1007/s00268-007-9096-1", "nctId": null, "pmcid": null, "title": "Effects of warm water sitz bath on symptoms in post-anal sphincterotomy in chronic anal fissure--a randomized and controlled study", "firstAuthor": "Gupta", "multipleAuthors": false, "journal": "World J Surg", "year": 2007, "design": "rct", "n": 46, "nField": "reported", "population": "patients recovering after surgery (sphincterotomy) for chronic anal fissure", "intervention": "warm water sitz bath twice daily plus fiber and pain medicine", "comparator": "fiber and pain medicine alone, no sitz bath", "primaryOutcome": "pain level, anal burning after bowel movements, and symptom improvement measured on a visual analog scale", "result": "no significant difference in pain scores between groups, but significantly less anal burning in the sitz bath group, and a non-significant trend toward better improvement scores", "resultDirection": "mixed", "quality": "low", "qualityWhy": "Small trial of only 46 post-surgical patients looking at symptom relief, not fissure healing itself, so results may not generalize to healing of an untreated fissure.", "directness": "indirect", "limitations": "Small sample size; studies post-operative symptom relief after sphincterotomy rather than fissure healing in unoperated patients; improvement score difference did not reach statistical significance.", "followUp": "one week", "plainFinding": "Less burning, no pain difference.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/17534541/", "sourceText": "BACKGROUND: Sitz bath is frequently recommended by physicians for a variety of anal disorders including anal fissure. The aim of the present study was to determine whether sitz bath does have any therapeutic properties improving upon a patient's postoperative symptoms after a closed lateral sphincterotomy. MATERIALS AND METHODS: Forty-six patients were randomly assigned to receive analgesics and fiber supplement alone (control patients) or a twice-daily sitz bath along with identical fiber and analgesics (sitz bath group). A 24-h pain score--post-defecation anal burning and symptom improvement--was evaluated on a visual analog scale (VAS). RESULTS: The groups were equally matched for age, gender distribution, and duration of disease. No significant difference in mean pain score between groups (p = 0.284) was noticed after one week. However, the patients from the control group experienced significant anal burning compared with patients from sitz bath group (p < 0.0001). The improvement score was higher in the sitz bath group when compared with the control group; however, it did not reached a statistically significant level. CONCLUSIONS: Patients after sphincterotomy for anal fissure receiving sitz bath experienced similar levels of pain when compared with those not receiving sitz bath. However, they reported a significant relief in anal burning and a marginally better satisfaction score and no reported adverse side effects.", "provenance": [ { "field": "n", "quote": "Forty-six patients were randomly assigned" }, { "field": "population", "quote": "improving upon a patient's postoperative symptoms after a closed lateral sphincterotomy" }, { "field": "intervention", "quote": "a twice-daily sitz bath along with identical fiber and analgesics (sitz bath group)" }, { "field": "comparator", "quote": "analgesics and fiber supplement alone (control patients)" }, { "field": "primaryOutcome", "quote": "A 24-h pain score--post-defecation anal burning and symptom improvement--was evaluated on a visual analog scale (VAS)" }, { "field": "result", "quote": "No significant difference in mean pain score between groups (p = 0.284) was noticed after one week. However, the patients from the control group experienced significant anal burning compared with patients from sitz bath group (p < 0.0001). The improvement score was higher in the sitz bath group when compared with the control group; however, it did not reached a statistically significant level." } ] }, { "id": "pmid:16916391", "pmid": "16916391", "doi": "10.1111/j.1445-2197.2006.03838.x", "nctId": null, "pmcid": null, "title": "Randomized, controlled study comparing sitz-bath and no-sitz-bath treatments in patients with acute anal fissures", "firstAuthor": "Gupta", "multipleAuthors": false, "journal": "ANZ J Surg", "year": 2006, "design": "rct", "n": 58, "nField": "reported", "population": "patients with acute anal fissures", "intervention": "sitz baths (soaking in warm water) plus psyllium husk", "comparator": "no sitz baths, psyllium husk alone", "primaryOutcome": "pain scores and fissure healing", "result": "no significant difference in healing or pain relief, though satisfaction was higher with sitz baths", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "small trial with some dropouts and no significant effect on the main outcomes of healing or pain", "directness": "direct", "limitations": "only 52 of 58 patients completed the trial; pain and healing differences did not reach statistical significance", "followUp": "4 weeks", "plainFinding": "No real improvement in healing or pain.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/16916391/", "sourceText": "AIM: To determine the efficacy and safety of sitz baths in the management of acute anal fissures. METHOD: Individual patients were randomized to either receive sitz baths or no sitz baths for 4 weeks in addition to oral psyllium husk. Patients were asked to soak their hips and buttocks in a tub containing plain lukewarm water for 10 min, once after defecation in the morning and again at bedtime. Each week, the patients were called to assess pain scores and healing of fissures, whereas the level of satisfaction was recorded at the end of 4 weeks. Main outcome measures were validated pain scores and levels of satisfaction. RESULTS: Fifty-eight subjects were recruited for this study. In all, 52 of them completed the trial (27 in the sitz bath group and 25 in the control group). Although the pain score was lesser in the sitz bath group than in the control group, it failed to reach statistical significance. There were no significant differences in fissure healing between the two groups over the 4-week study period. However, patients in the sitz bath group reported better satisfaction levels than the control group (P < 0.01). Although no serious adverse effects were observed, two patients from sitz bath group developed perianal skin rash. CONCLUSION: This study suggests that sitz baths improve patient satisfaction in acute anal fissures. However, the healing and overall pain relief was not significant enough to attract attention. It was also found to be associated with adverse effects in few patients.", "provenance": [ { "field": "n", "quote": "Fifty-eight subjects were recruited for this study." }, { "field": "population", "quote": "To determine the efficacy and safety of sitz baths in the management of acute anal fissures." }, { "field": "intervention", "quote": "Individual patients were randomized to either receive sitz baths or no sitz baths for 4 weeks in addition to oral psyllium husk." }, { "field": "comparator", "quote": "Individual patients were randomized to either receive sitz baths or no sitz baths for 4 weeks in addition to oral psyllium husk." }, { "field": "primaryOutcome", "quote": "Main outcome measures were validated pain scores and levels of satisfaction." }, { "field": "result", "quote": "There were no significant differences in fissure healing between the two groups over the 4-week study period." }, { "field": "result", "quote": "Although the pain score was lesser in the sitz bath group than in the control group, it failed to reach statistical significance." } ] }, { "id": "pmid:15881700", "pmid": "15881700", "doi": null, "nctId": null, "pmcid": null, "title": "Current treatment options for fissure-in-ano", "firstAuthor": "Gupta", "multipleAuthors": false, "journal": "J Med Liban", "year": 2004, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with anal fissures (acute and chronic)", "intervention": "various surgical and pharmacological treatments for anal fissure (not specifically sitz baths)", "comparator": "different treatment methods compared to each other", "primaryOutcome": "cure rates and complications of fissure treatments", "result": "Surgery is still recommended as the preferred treatment after drug treatments fail, but the abstract does not discuss sitz baths at all", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a general review of fissure treatments that never mentions or evaluates sitz baths, so it provides no evidence on the specific question.", "directness": "indirect", "limitations": "The abstract is a general narrative review of surgical and pharmacological fissure treatments and does not address sitz baths or warm water soaks at all.", "followUp": "", "plainFinding": "Does not address sitz baths.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/15881700/", "sourceText": "BACKGROUND: Fissure-in-ano is a painful condition that affects a sizable majority of the population. Selecting a method of treating the condition that could achieve optimal clinical results and the least pain and inconvenience to the patient has always posed a challenge to the surgeons. This led to the innovation of a number of surgical and pharmacological methods that relax the anal muscle. While acute fissures could be managed with medical therapy alone, chronic fissures do need some form of manipulation to relieve internal sphincter spasm. MATERIALS AND METHODS: The present study discusses various techniques advocated for the treatment of acute and chronic fissure-in-ano. It also elaborates on the advantages and deficiencies of each. DISCUSSION: Despite the initial success with pharmacological agents in the treatment of patients with chronic anal fissures, a growing concern is developing about their use. Increasing incidence of adverse effects and decreasing long-term efficacy have been the major drawbacks. CONCLUSION: Surgery still remains the preferred option which should be offered to patients with relapse or therapeutic failure with prior pharmacological treatment. Nevertheless, the patient should be informed about the pros and cons of each mode of treatment with details of cure rates and possible complications.", "provenance": [ { "field": "population", "quote": "Fissure-in-ano is a painful condition that affects a sizable majority of the population." }, { "field": "intervention", "quote": "a number of surgical and pharmacological methods that relax the anal muscle" }, { "field": "comparator", "quote": "The present study discusses various techniques advocated for the treatment of acute and chronic fissure-in-ano." }, { "field": "primaryOutcome", "quote": "details of cure rates and possible complications" }, { "field": "result", "quote": "Surgery still remains the preferred option which should be offered to patients with relapse or therapeutic failure with prior pharmacological treatment." } ] }, { "id": "pmid:15521346", "pmid": "15521346", "doi": null, "nctId": null, "pmcid": null, "title": "[A prospective, randomized double-blind study on the treatment of anal fissures with Nitroglycerin ointment]", "firstAuthor": "Weinstein", "multipleAuthors": true, "journal": "Harefuah", "year": 2004, "design": "rct", "n": 48, "nField": "reported", "population": "patients suffering from chronic anal fissure", "intervention": "Nitroglycerin ointment (0.2% or 0.4%) combined with stool softeners and sitz baths", "comparator": "placebo ointment combined with stool softeners and sitz baths", "primaryOutcome": "fissure healing and pain relief", "result": "No significant difference was found between the groups regarding healing or pain relief", "resultDirection": "no-benefit", "quality": "low", "qualityWhy": "It was a small, double-blind randomized trial but nearly a third of patients dropped out, which weakens confidence in the result.", "directness": "indirect", "limitations": "Small sample size (48 patients), high dropout rate (31%), and all groups also received sitz baths and stool softeners, so the trial cannot isolate the effect of sitz baths alone.", "followUp": "", "plainFinding": "Nitroglycerin added no extra benefit.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/15521346/", "sourceText": "BACKGROUND: Anal fissure is a common disease. Treatment includes conservative measures or surgery. One of the treatment options is topical Nitroglycerin ointment. MATERIALS AND METHODS: We present a prospective, randomized, double-blind study, encompassing 48 patients suffering from chronic anal fissure. The subjects were divided into three groups according to the dose of Nitroglycerin ointment received--group I--0% (placebo), group II--0.2% (0.75 mg) and group III--0.4% (1.5 mg). Demographic data, medical history and physical findings were recorded. Healing, pain relief and adverse events were evaluated during and after the treatment period. RESULTS: No significant difference (p<0.05) was found between the groups with respect to patient age, gender, past history, physical examination, amount of ointment used and adverse events. Thirty three of the 48 (69%) patients completed the study. No significant differences were found between the groups with respect to the reasons and rates of leaving the study (p=0.494). Fifteen patients failed to complete the study; eight patients (17%) due to headaches, one patient was operated upon and six patients left the study because of cooperation problems. No significant difference was found between the groups regarding healing (p=0.952) or pain relief (p=0.458-0.8 according to the type of pain checked). CONCLUSIONS: According to our study, there was no benefit regarding healing or pain relief, in treating patients suffering from an anal fissure with Nitroglycerin ointment in combination with stool softeners and sitz baths, compared to the same treatment without Nitroglycerin ointment.", "provenance": [ { "field": "n", "quote": "encompassing 48 patients suffering from chronic anal fissure" }, { "field": "population", "quote": "patients suffering from chronic anal fissure" }, { "field": "intervention", "quote": "Nitroglycerin ointment" }, { "field": "comparator", "quote": "group I--0% (placebo)" }, { "field": "primaryOutcome", "quote": "Healing, pain relief and adverse events were evaluated" }, { "field": "result", "quote": "No significant difference was found between the groups regarding healing (p=0.952) or pain relief (p=0.458-0.8 according to the type of pain checked)." }, { "field": "limitations", "quote": "there was no benefit regarding healing or pain relief, in treating patients suffering from an anal fissure with Nitroglycerin ointment in combination with stool softeners and sitz baths, compared to the same treatment without Nitroglycerin ointment." } ] }, { "id": "pmid:12402050", "pmid": "12402050", "doi": "10.1007/s101510200017", "nctId": null, "pmcid": null, "title": "Oral lacidipine in the treatment of anal fissure", "firstAuthor": "Ansaloni", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2002, "design": "case-series", "n": 21, "nField": "reported", "population": "patients with anal fissure", "intervention": "oral lacidipine plus warm sitz baths", "comparator": "none (no control group)", "primaryOutcome": "healing of the anal fissure", "result": "19 of 21 fissures (90.4%) healed after 28 days of combined treatment", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This was a small, uncontrolled study of 21 patients with no comparison group, so it cannot show whether sitz baths themselves contributed to healing.", "directness": "indirect", "limitations": "No control or comparator group, small sample size, and sitz baths were given alongside oral lacidipine so their individual effect cannot be separated.", "followUp": "2 months", "plainFinding": "Mostly healed, but effect unclear", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/12402050/", "sourceText": "The aim of this prospective study was to assess the effectiveness in healing anal fissure (AF) of lacidipine, a calcium channel blocker with a better tolerability in comparison to other calcium antagonists. Twenty-one consecutive patients (16 women, 76.2%) with AF (16 chronic, situated posteriorly in 17 patients (81.0%), anteriorly in 4) with a mean age of 37.1 years (SD, 13.6, range, 20-6) were treated with oral lacidipine (6 mg daily) and warm sitz baths for 28 days, adding only stool softeners for patients with constipation. Blood pressure, pain scores (assessed from 0 to 10 on a visual analogue scale) and fissure healing were monitored at 14 days, 28 days and 2 months. At the 14-day and 28-day follow-ups, the mean systolic and diastolic pressures were not significantly different from pre-treatment levels. Seven patients (33.3%) developed side effects, but only one, who developed dyplopia, withdrew from the study at the 14-day control (non-compliance rate with treatment, 4.8%). Pain scores were significantly reduced after 14 days and continued to show a significant reduction throughout the treatment period. Three fissures (14.3%) healed by 14 days and a total of 19 (90.4%) after 28 days: among the healed AF no recurrences were seen at the 2-month control. Among the two treatment failures, one was the patient who withdrew from the study at the 14-day control due to dyplopia and the other was a patient who failed to heal up to the 2-month follow-up, although completely asymptomatic. Both patients underwent left lateral sphincterotomy and healed. In conclusion, oral lacedipine is quite well tolerated and may offer a promising alternative treatment for AF.", "provenance": [ { "field": "n", "quote": "Twenty-one consecutive patients" }, { "field": "population", "quote": "consecutive patients (16 women, 76.2%) with AF" }, { "field": "intervention", "quote": "treated with oral lacidipine (6 mg daily) and warm sitz baths for 28 days" }, { "field": "comparator", "quote": "adding only stool softeners for patients with constipation" }, { "field": "primaryOutcome", "quote": "fissure healing were monitored at 14 days, 28 days and 2 months" }, { "field": "result", "quote": "a total of 19 (90.4%) after 28 days: among the healed AF no recurrences were seen at the 2-month control" } ] }, { "id": "pmid:10626860", "pmid": "10626860", "doi": "10.1016/s0022-3468(99)90318-4", "nctId": null, "pmcid": null, "title": "A prospective, randomized, double-blind, placebo-controlled trial of glyceryl-trinitrate ointment in the treatment of children with anal fissure", "firstAuthor": "Tander", "multipleAuthors": true, "journal": "J Pediatr Surg", "year": 1999, "design": "rct", "n": 65, "nField": "reported", "population": "children with anal fissure", "intervention": "glyceryl-trinitrate (GTN) ointment applied to the anal canal", "comparator": "placebo ointment (and separately lidocaine ointment)", "primaryOutcome": "complete healing of the fissure", "result": "26 of 31 (83.9%) healed with GTN versus 6 of 17 (35.2%) with placebo, a statistically significant difference", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "It was a randomized, double-blind, placebo-controlled trial, but it was small and tested an ointment, not sitz baths.", "directness": "indirect", "limitations": "The abstract does not mention sitz baths as a tested intervention; it only lists them as part of usual background care, and the trial itself examined GTN ointment versus lidocaine and placebo.", "followUp": "8 weeks", "plainFinding": "Nitroglycerin ointment helped, not sitz baths tested.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/10626860/", "sourceText": "BACKGROUND: Anal fissure in children usually is treated by sitz baths, stool softeners, and analgesic ointments. However, some cases are intractable to the treatment. In recent years, it has been reported that nitric oxide donors such as local glyceryl-trinitrate (GTN) ointment causes a reversible chemical sphincterotomy. Although the GTN ointment can be an alternative therapy for adult cases, it has not yet been studied in the children who suffer from anal fissure. METHODS: Sixty-five children with anal fissure were divided randomly into 3 groups. Each group received double-blinded a topical ointment that contained either 0.2% GTN, 10% lidocaine, or placebo. These ointments were applied to the lowest part of the anal canal twice daily. Patients were periodically reviewed, and the study was ended after 8 weeks. RESULTS: Complete healing of the fissure occurred in 26 of 31 (83.9%) patients treated with GTN, 7 of 14 (50%) patients treated with lidocaine, and 6 of 17 (35.2%) treated with placebo. In 29 of 31 (93.5%) GTN-treated patients, a total relief of symptoms was observed, whereas this occurred in 7 of 14 (50%) treated with lidocaine and 6 of 11 (35.3%) in the placebo group. The differences between the study group and control groups were highly statistically significant (P < .001). CONCLUSION: The majority of children suffering from anal fissure will be cured and have relief of symptoms after topical application of GTN ointment to the anal canal.", "provenance": [ { "field": "population", "quote": "Sixty-five children with anal fissure were divided randomly into 3 groups." }, { "field": "intervention", "quote": "0.2% GTN" }, { "field": "comparator", "quote": "either 0.2% GTN, 10% lidocaine, or placebo" }, { "field": "primaryOutcome", "quote": "Complete healing of the fissure occurred" }, { "field": "result", "quote": "Complete healing of the fissure occurred in 26 of 31 (83.9%) patients treated with GTN, 7 of 14 (50%) patients treated with lidocaine, and 6 of 17 (35.2%) treated with placebo." }, { "field": "n", "quote": "Sixty-five children with anal fissure were divided randomly into 3 groups." }, { "field": "followUp", "quote": "the study was ended after 8 weeks" } ] }, { "id": "pmid:8921768", "pmid": "8921768", "doi": "10.1016/s0733-8627(05)70278-9", "nctId": null, "pmcid": null, "title": "Anorectal disorders", "firstAuthor": "Janicke", "multipleAuthors": true, "journal": "Emerg Med Clin North Am", "year": 1996, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with anorectal disorders including anal fissures", "intervention": "sitz baths, stool softeners, and analgesics", "comparator": "no comparator stated", "primaryOutcome": "healing or resolution of anal fissure", "result": "described as adequate treatment for most anal fissures, but no data or statistics given", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a general review article with no study data, numbers, or methods supporting the claim about sitz baths.", "directness": "direct", "limitations": "No original data, no patient numbers, no comparison group, and no description of study methodology; general clinical review statement only.", "followUp": "", "plainFinding": "Said to help, no evidence given.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/8921768/", "sourceText": "Anorectal disorders are commonly encountered in the practice of emergency medicine. Most can be diagnosed and treated in the emergency department setting. Almost all anorectal disorders once diagnosed and treated in the emergency department need appropriate follow-up to ensure adequacy of treatment, for further possible diagnostic procedures (e.g., endoscopy, biopsy), or for definitive treatment. Hemorrhoids are the most prevalent anorectal disorder and are the most common cause of hematochezia. Treatment is dependent on the degree of hemorrhoid prolapse and symptoms. Most cases can be treated by conservative medical treatment (e.g., dietary changes, sitz baths) or nonsurgical procedures (e.g., rubber band liagation, infrared coagulation). Surgical excision of symptomatic thrombosed external hemorrhoids is indicated if within 48 to 72 hours of pain onset. Anal fissures are one of the most common causes of anorectal pain. They are most frequently idiopathic, and most are located in the posterior midline of the anal canal. Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics. If the anal fissure becomes chronic and is not responsive to medical therapy, a lateral sphincterotomy of the internal anal sphincter is the surgical procedure of choice. Pharmacologic treatment (botulinum toxin or nitroglycerin ointment) to decrease internal anal sphincter tone has shown promise in the treatment of anal fissure. Anorectal abscesses are categorized into four types: perianal, ischiorectal, intersphincteric, and supralevator. Most are idiopathic and contain mixed aerobic-anaerobic pathogens. Fistula formation varies from 25% to 50% and is much more common with gut-derived organisms (e.g., E. coli, B. fragilis). Definitive treatment for an anorectal abscess is timely surgical incision and drainage to prevent more serious complications (e.g., serious infection, extension of the abscess). Anal carcinomas are infrequent, the majority of them being squamous cell or epidermoid carcinomas. The emergency physician must maintain a high index of suspicion and obtain a biopsy of suspicious lesions in order not to miss the diagnosis of a cancer. The most common presenting complaint of anal tumors is rectal bleeding. Combination chemotherapy and radiotherapy have shown promising results in the treatment of anal canal tumors. Bacterial, viral, and protozoal infections can be transmitted to the anorectum via anoreceptive intercourse. Such infections must be considered when a patient presents with rectal pain or discharge, tenesmus, or rectal or perineal ulcers. Proctosigmoidoscopy and rectal cultures may be necessary to determine the cause. Potential rectal complications of HIV infection include infectious diarrhea, acyclovir-resistant strains of HSV2, Kaposi's sarcoma, lymphoma, and squamous cell carcinoma. Rectal injuries may result from penetrating or blunt trauma, iatrogenic injuries, or foreign bodies. Rectal injury should be suspected when a patient presents with low abdominal, pelvic, or perineal pain or blood per rectum after sustaining trauma or undergoing an endoscopic or surgical procedure. Tetanus prophylaxis, intravenous antibiotics, and surgical intervention are indicated in all but superficial rectal tears.", "provenance": [ { "field": "population", "quote": "Anal fissures are one of the most common causes of anorectal pain." }, { "field": "intervention", "quote": "Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics." }, { "field": "comparator", "quote": "If the anal fissure becomes chronic and is not responsive to medical therapy, a lateral sphincterotomy of the internal anal sphincter is the surgical procedure of choice." }, { "field": "primaryOutcome", "quote": "Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics." }, { "field": "result", "quote": "Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics." } ] }, { "id": "pmid:8843260", "pmid": "8843260", "doi": null, "nctId": null, "pmcid": null, "title": "The management of infectious and noninfectious anorectal complications in patients with leukemia", "firstAuthor": "North", "multipleAuthors": true, "journal": "J Am Coll Surg", "year": 1996, "design": "retrospective", "n": 83, "nField": "reported", "population": "patients with leukemia who developed anal and rectal problems during treatment, including 22 with anal fissures", "intervention": "non-surgical treatment (described as antibiotics and sitz baths for infected problems, general non-surgical care for non-infected problems like fissures)", "comparator": "surgery (incision and drainage)", "primaryOutcome": "whether the anal/rectal problem resolved without surgery", "result": "86% of the 92 anorectal complications resolved without surgery; the abstract does not give a fissure-specific healing rate for sitz baths", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a retrospective chart review in leukemia patients lumping fissures together with abscesses, hemorrhoids and ulcers, with no fissure-specific outcome data and no control group for sitz baths alone.", "directness": "indirect", "limitations": "Retrospective design, results pooled across several different anorectal conditions rather than reported separately for fissures, no untreated or alternative-treatment comparison group, and the study population (immunocompromised leukemia patients) differs from typical anal fissure patients.", "followUp": "", "plainFinding": "No fissure-specific sitz bath result given", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/8843260/", "sourceText": "BACKGROUND: Infectious and noninfectious anorectal complications may occur in patients undergoing therapy for leukemia. Controversy surrounds the treatment of this problem in immunocompromised patients. STUDY DESIGN: A retrospective review of the medical records of 83 patients with acute or chronic leukemia in whom anorectal disease developed during inpatient therapy for leukemia was performed to determine the initial signs and symptoms, treatment, and outcomes. RESULTS: During a 12-year period, 92 patients with anorectal complications were treated. This series included 25 patients with perirectal abscesses, 22 patients with anal fissures, 18 patients with symptomatic external hemorrhoids, 12 patients with perianal ulcerations, 12 patients with symptomatic internal hemorrhoids, and three patients with fistulas in ano. Overall, 79 (86 percent) of the 92 anorectal complications resolved in 68 of the 83 patients. Increasing periods of neutropenia did not adversely affect the resolution of anorectal disease. Thirteen patients (16 percent) required surgical intervention, most commonly secondary to a perirectal abscess. Incision and drainage was necessary in ten (40 percent) of 25 patients with perirectal abscess, which included five patients with fluctuation and five patients in whom infection failed to respond to medical therapy. CONCLUSIONS: Noninfectious anorectal complications in patients with leukemia respond to nonoperative intervention and rarely progress to a life-threatening infection. Nonoperative intervention in the form of systemic antibiotics and sitz baths is successful in the treatment of infectious anorectal complications. Incision and drainage should be performed when fluctuation is present and in patients whose complications fail to respond to medical therapy.", "provenance": [ { "field": "n", "quote": "A retrospective review of the medical records of 83 patients with acute or chronic leukemia" }, { "field": "population", "quote": "22 patients with anal fissures" }, { "field": "intervention", "quote": "Nonoperative intervention in the form of systemic antibiotics and sitz baths is successful in the treatment of infectious anorectal complications." }, { "field": "comparator", "quote": "Incision and drainage should be performed when fluctuation is present and in patients whose complications fail to respond to medical therapy." }, { "field": "primaryOutcome", "quote": "Overall, 79 (86 percent) of the 92 anorectal complications resolved in 68 of the 83 patients." }, { "field": "result", "quote": "Noninfectious anorectal complications in patients with leukemia respond to nonoperative intervention and rarely progress to a life-threatening infection." } ] }, { "id": "pmid:3011180", "pmid": "3011180", "doi": "10.1136/bmj.292.6529.1167", "nctId": null, "pmcid": "PMC1340178", "title": "Treatment of first episodes of acute anal fissure: prospective randomised study of lignocaine ointment versus hydrocortisone ointment or warm sitz baths plus bran", "firstAuthor": "Jensen", "multipleAuthors": false, "journal": "Br Med J (Clin Res Ed)", "year": 1986, "design": "rct", "n": 103, "nField": "reported", "population": "adults with a first episode of acute anal fissure", "intervention": "warm sitz baths plus unprocessed bran", "comparator": "lignocaine ointment or hydrocortisone ointment", "primaryOutcome": "symptom relief and fissure healing after 3 weeks", "result": "sitz baths plus bran gave faster symptom relief and highest healing rate (87%) versus 60% with lignocaine and 82.4% with hydrocortisone; by 3 weeks symptom relief was similar across groups", "resultDirection": "benefit", "quality": "moderate", "qualityWhy": "it was a randomised trial but small, with some patients dropped for not following the protocol, which can affect the reliability of results", "directness": "direct", "limitations": "seven patients withdrawn for protocol non-adherence; healing assessed only up to three weeks", "followUp": "three week", "plainFinding": "Sitz baths plus bran healed fissures best.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/3011180/", "sourceText": "One hundred and three patients with an acute first episode of posterior anal fissure were randomised to receive a three week trial of lignocaine ointment (n = 33) versus hydrocortisone ointment (n = 35) or warm sitz baths combined with an intake of unprocessed bran (n =35). Seven patients were withdrawn owing to failure to adhere to the trial protocol. After one and two weeks of treatment symptomatic relief was significantly better among patients treated with sitz baths and bran than among patients treated with lignocaine ointment or hydrocortisone ointment. After three weeks there was no difference in symptomatic relief among the three groups. Patients treated with lignocaine, however, had significantly fewer healed fissures (60%) than patients treated with hydrocortisone (82.4%) or warm sitz baths and bran (87%). In this study warm sitz baths plus an intake of unprocessed bran came out as the treatment of choice for an acute first episode of posterior anal fissure. This treatment is cheap, has no potential serious side effects, and brings the best and quickest relief of symptoms.", "provenance": [ { "field": "n", "quote": "One hundred and three patients with an acute first episode of posterior anal fissure were randomised" }, { "field": "population", "quote": "patients with an acute first episode of posterior anal fissure" }, { "field": "intervention", "quote": "warm sitz baths combined with an intake of unprocessed bran" }, { "field": "comparator", "quote": "lignocaine ointment (n = 33) versus hydrocortisone ointment (n = 35)" }, { "field": "primaryOutcome", "quote": "symptomatic relief was significantly better among patients treated with sitz baths and bran" }, { "field": "result", "quote": "Patients treated with lignocaine, however, had significantly fewer healed fissures (60%) than patients treated with hydrocortisone (82.4%) or warm sitz baths and bran (87%)." } ] } ], "faqs": [ { "q": "Will a sitz bath heal my fissure?", "a": "Based on these studies, it's unclear. Some trials found no difference in healing or pain when sitz baths were added to care, while another found higher healing with a full sitz-bath routine compared with ointments. No trial has compared sitz baths against doing nothing at all." }, { "q": "Should I stop taking sitz baths?", "a": "There's no need to stop. No harm from warm sitz baths was reported in these studies, and some people found them soothing or more satisfying, even when measured healing wasn't different." }, { "q": "What actually heals anal fissures, based on these studies?", "a": "Treatments like topical nitroglycerin, diltiazem, and botulinum toxin injection showed clearer evidence of healing in some trials, usually used alongside sitz baths and stool softeners. Surgery healed more fissures than sitz baths alone in one review." }, { "q": "How did the studies have people do a sitz bath?", "a": "Soaking the anal area in warm water, generally described as above 30°C, for short periods, often a few times a day. One trial found no extra benefit from using cold water instead of warm." }, { "q": "Why do the studies disagree?", "a": "Most studies gave sitz baths to everyone, so they couldn't test sitz baths on their own. The few trials that did isolate sitz baths found no healing benefit, while a different trial comparing a whole sitz-bath routine to ointments found better healing with the sitz-bath routine." } ], "patientTakeaway": "Warm sitz baths seem safe, and some people find them soothing, but the trials that tested this directly don't agree on whether sitz baths actually speed up healing of an anal fissure. If you have a fissure, keep doing sitz baths if they help you feel better, but also focus on steps with stronger trial evidence — more fibre and fluids, stool softeners, and asking your doctor about topical treatments like nitroglycerin or diltiazem. See a doctor if the fissure hasn't improved after a few weeks.", "methodology": { "databases": [ "PubMed", "ClinicalTrials.gov", "Crossref" ], "searchStrings": { "pubmed": "(\"Fissure in Ano\"[Mesh] OR \"anal fissure\"[tiab]) AND (\"sitz bath\"[tiab] OR \"sitz baths\"[tiab] OR \"warm water\"[tiab] OR \"Baths\"[Mesh])" }, "pubmedQueryTranslation": "(\"Fissure in Ano\"[MeSH Terms] OR \"anal fissure\"[Title/Abstract]) AND (\"sitz bath\"[Title/Abstract] OR \"sitz baths\"[Title/Abstract] OR \"warm water\"[Title/Abstract] OR \"Baths\"[MeSH Terms])", "searchedOn": "2026-10-05", "inclusion": [ "Human, animal or laboratory studies reporting an outcome relevant to the question" ], "exclusion": [ "Records about a different condition or intervention", "Records reporting no outcome", "Retracted publications, which are listed but excluded from every count" ], "extractionLevel": "abstract", "gradingNote": "Evidence strength is adapted from the GRADE framework. It is not a GRADE assessment and was not produced by a GRADE panel.", "limits": [ "Fields were read from abstracts, not full text, so detail reported only in a paper's methods section is not captured." ] }, "seo": { "title": "Do Sitz Baths Help Heal an Anal Fissure?", "description": "9 randomised trials disagree on whether sitz baths speed anal fissure healing — the evidence is unclear and low certainty." }, "lastChecked": "2026-10-05", "lastChanged": "2026-10-05", "nextCheckDue": "2026-11-05", "history": [], "pipeline": { "screenModel": "claude-haiku-4-5", "extractModel": "claude-sonnet-5", "composeModel": "claude-sonnet-5", "promptVersion": "ev-1", "ranOn": "2026-10-05" }, "status": "published" }