What are the treatment options for anal fissures?

Treatment Options for Anal Fissures

The first-line treatment for anal fissures should be non-operative management with dietary and lifestyle changes, including increased fiber and water intake, as this approach is risk-free and resolves approximately 50% of cases without further intervention. 1

Diagnosis and Initial Assessment

Anal fissures present with:

• Severe pain during and after defecation (sometimes lasting hours)
• Bright red, scanty bleeding
• Visible split in the squamous epithelium at or just inside the anal verge
• Usually located in the posterior midline (90%)

Key physical findings include:

• Sentinel skin tag distal to the fissure
• Hypertrophied anal papilla at proximal margin
• Signs of chronicity: fibrosis and visible internal sphincter muscle at fissure base

Warning: Off-midline fissures require investigation for underlying conditions like Crohn's disease, HIV/AIDS, ulcerative colitis, tuberculosis, syphilis, leukemia, or cancer 1

Treatment Algorithm

Step 1: Conservative Management (First-Line)

• Fiber supplementation and adequate fluid intake
• Sitz baths
• Topical analgesics
• Pain management with topical anesthetics and common pain killers if needed 1

This approach resolves approximately 50% of all fissures, with acute fissures more likely to heal than chronic ones 1.

Step 2: Medical Therapy (For persistent fissures)

If conservative measures fail after 2-4 weeks, consider:

1. Topical Therapy Options:

   • Topical nitroglycerin (GTN) ointment: Works by decreasing anal sphincter pressure

     • Healing rates vary from 25-80% 1
     • Common side effect: headaches (can be significant) 2

   • Topical calcium channel blockers: Similar efficacy to GTN with fewer side effects 1

2. Botulinum Toxin Injection:

   • High cure rates (75-95%) with low morbidity 1
   • Provides temporary sphincter relaxation
   • Optimal injection location remains controversial
   • Nearly as effective as surgery without significant adverse effects 3

Step 3: Surgical Management (For refractory cases)

Consider surgery if non-operative management fails after 8 weeks 1:

• Lateral Internal Sphincterotomy (LIS):
  • Most effective procedure with healing rates >95% and low recurrence (1-3%) 3
  • Superior to topical nitroglycerin (93% vs 50% success rate) 4
  • Provides rapid symptom relief
  • Key concern: risk of minor but sometimes permanent defects in continence 1

Important Considerations

• Manual dilatation should be avoided due to risk of sphincter damage 1
• Chronic fissures (>2 months) are more difficult to treat with conservative measures alone
• Surgical treatment is not recommended for acute fissures 1
• Topical antibiotics may be considered in cases of poor genital hygiene 1

Efficacy Comparison

• Conservative measures: ~50% healing rate, no side effects 1
• Topical nitroglycerin: 41-56% healing rate, high incidence of headaches (75% of patients) 2
• Botulinum toxin: 75-95% healing rate, minimal side effects 1, 3
• Lateral internal sphincterotomy: >95% healing rate, risk of incontinence (up to 7%) 3, 4

The treatment approach should follow this stepwise algorithm, with surgery reserved for cases that fail conservative and medical management, balancing the benefits of healing against the risk of incontinence.