From the Guidelines
Anal fissures should be initially managed with non-operative measures, including dietary and lifestyle changes, as recommended by the most recent guidelines 1. The management of anal fissures typically follows a stepwise progression, starting with conservative measures.
- Increased dietary fiber (25-30g daily) and adequate hydration are essential to soften stool and reduce trauma during defecation.
- Sitz baths (warm water soaks for 10-15 minutes, 2-3 times daily) and stool softeners like docusate sodium (100mg twice daily) can also help reduce pain and promote healing. If conservative management fails, topical medications are the next step, with options including:
- Topical nitroglycerin (0.2-0.4% ointment applied twice daily for 6-8 weeks)
- Calcium channel blockers like diltiazem (2% ointment applied 3-4 times daily for 6-8 weeks), which work by relaxing the internal anal sphincter and improving blood flow. Botulinum toxin injection (20-100 units) into the internal sphincter is another option, providing temporary chemical sphincterotomy for 2-3 months. For persistent fissures unresponsive to medical therapy after 8-12 weeks, surgical intervention may be necessary, with lateral internal sphincterotomy being the gold standard surgical procedure, as it has healing rates exceeding 95% 1. This procedure involves partial division of the internal anal sphincter to reduce pressure and promote healing. Fissurectomy or advancement flap procedures may be considered in specific cases, particularly for recurrent or anterior fissures in women. Most anal fissures (80-90%) will heal with conservative and medical management, making surgery necessary only for chronic, refractory cases. It is essential to note that the choice of treatment should be based on the individual patient's needs and the severity of their symptoms, as well as the potential risks and benefits of each treatment option 1.
From the Research
Management Options for Anal Fissures
- Conservative management using increased fiber and warm baths can result in healing of approximately half of all anal fissures 2
- Pharmacologic options, such as nitroglycerin ointment, botulinum toxin, and calcium channel blockers, can offer satisfactory cure rates for fissures that fail conservative care 2, 3, 4
- Lateral internal sphincterotomy remains the gold standard for definitive management of anal fissure, but it carries a risk of incontinence 2, 4
- Botulinum toxin injections have been proposed as a safe and effective alternative to surgery, with a healing rate of 77.7% in one study 5
- Chemical sphincterotomy using agents such as topical glyceryl trinitrate, calcium channel blockers, and botulinum toxin is considered a first-line treatment for chronic anal fissure, with negligible side effects 6
Comparison of Treatment Options
- Medical therapy for chronic anal fissure may be applied with a chance of cure that is marginally better than placebo, but is far less effective than surgery 3
- Nitroglycerin ointment was found to be marginally but significantly better than placebo in healing anal fissure, but late recurrence of fissure was common 3
- Botulinum toxin and calcium channel blockers were equivalent to nitroglycerin ointment in efficacy, with fewer adverse events 3, 4