At a glance
You have been using a topical treatment — GTN, diltiazem, or both — and your fissure is still causing pain. This is a frustrating but common situation. Topical treatments help many people, but they do not work for everyone. If your fissure has not responded after a reasonable trial period, there are clear next steps to consider.
This guide covers what “not healing” actually means, common reasons topical treatment may not be enough, and the options people typically move to next.
What counts as not healing
There is no single definition, but clinicians generally look for these patterns:
- No improvement after 6 to 8 weeks of consistent use
- Some improvement that has plateaued — better than before, but the fissure is still clearly present
- Recurrence after initial healing — the fissure healed but came back when treatment stopped
- Intolerable side effects that prevented completing the course
The important distinction is between a treatment that was given a fair trial and one that was not. Inconsistent application, missed doses, or stopping early because of side effects may mean the topical treatment never had a proper chance to work.
Common reasons topical treatment falls short
Understanding why the treatment may not have worked can help guide the next conversation with your clinician.
The fissure has become chronic
Chronic fissures develop features that make them harder to heal: fibrosis around the edges, a sentinel pile, and sustained internal sphincter spasm. These structural changes can be beyond what a topical cream alone can address.
The sphincter spasm is too strong
Topical treatments work by relaxing the internal sphincter muscle, which increases blood flow to the fissure. But if the spasm is particularly entrenched, a cream applied to the surface may not penetrate deeply enough to break the cycle.
Application difficulties
Some people find it difficult to apply the cream correctly — to the internal sphincter rather than just the external skin. This is not a personal failing; it is a genuine practical challenge that can affect how well the medication reaches its target.
Stool management was not optimised
Topical treatment works best alongside good stool management. If stools remained hard or irregular during the treatment period, the fissure may have been re-injured faster than it could heal.
Before escalating: worth checking
Before moving to the next treatment, some people find it helpful to review these factors with their clinician:
- Were you using the cream correctly? — Applied to the inside of the anal canal, not just externally
- Was the frequency right? — Typically two to three times daily
- Were you managing your stools effectively? — Fibre, hydration, and softeners alongside the cream
- Did you complete a full course? — At least six to eight weeks of consistent use
- Were side effects managed? — Sometimes adjusting the dose or timing helps
If any of these were not fully in place, your clinician may suggest optimising conservative treatment before moving on.
The common next steps
Botox injection
Botox (botulinum toxin) injected into the internal sphincter is often the next step after topical treatment. It works on the same principle — relaxing the sphincter — but delivers the effect more directly and at a stronger level.
People commonly describe botox as:
- A brief procedure, usually done as a day case
- A waiting period of one to two weeks before effects become clear
- Effective for many people whose topical treatment was insufficient
- Temporary — the effect wears off after several months, during which the fissure ideally heals
Fissurectomy
Fissurectomy involves removing the chronic fissure tissue to create a fresh wound that can heal properly. It is sometimes combined with botox. People describe it as a reasonable option when the fissure has developed chronic features like a sentinel pile or fibrosis.
Lateral internal sphincterotomy (LIS)
LIS is a surgical procedure that makes a small, controlled cut in the internal sphincter muscle to permanently reduce its tone. It has the highest healing rate for chronic fissures but carries a small risk of changes to fine continence control.
People typically consider LIS when:
- Topical treatments and botox have not been sufficient
- The fissure is clearly chronic with structural changes
- The pain is significantly affecting quality of life
Continued conservative care
Some people choose to continue with conservative measures rather than escalating. This is a valid choice, particularly if:
- The fissure is manageable rather than severely painful
- There are medical reasons to avoid procedures
- You are not ready for the next step and want more time
How to approach the conversation
When discussing next steps with your clinician, it helps to be specific about:
- How long you have been using the cream and how consistently
- What has changed — even partial improvement is useful information
- Side effects you experienced and whether they affected your ability to use the treatment
- Your stool management routine — they may want to optimise this before escalating
- Your preferences — some people want to try the least invasive next option; others want the highest success rate
Your clinician sees this situation regularly. A topical treatment not being sufficient is a common part of the treatment pathway, not an unusual outcome.
Moving forward
Not responding to topical treatment can feel demoralising, especially after weeks of careful routine. But it is genuinely useful information. It tells you and your clinician that the fissure needs a different level of intervention — and there are effective options available.
The important thing is to have the conversation rather than continuing with something that is not working. Many people describe the period after deciding to escalate treatment as a relief — the uncertainty of waiting for a cream to work is replaced by a clear plan.