What are the treatment options for anal fissures?

Treatment Options for Anal Fissures

The most effective treatment approach for anal fissures begins with conservative management, including fiber supplementation, adequate fluid intake, sitz baths, and topical analgesics, as approximately 50% of all anal fissures will heal with these measures alone. 1

Initial Diagnosis and Assessment

Anal fissures present with:

• Severe anal pain during and after defecation (may last hours)
• Bright red, scanty bleeding
• Typical location: midline (90% posterior, 10% anterior)

Physical examination reveals:

• Split in squamous epithelium at or just inside anal verge
• Sentinel skin tag distal to fissure
• Hypertrophied anal papilla at proximal margin

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

Treatment Algorithm

First-Line Treatment: Conservative Management

• Strong recommendation for non-operative management initially 1
• Components:
  • Increased dietary fiber and water intake 1
  • Sitz baths (warm water soaks)
  • Topical analgesics
  • Stool softeners/bulk-forming laxatives

For pain control:

• Topical anesthetics and common pain medications for inadequate pain control 1
• Topical antibiotics may be considered in cases of poor genital hygiene 1

Second-Line Treatment: Medical Therapy

If conservative treatment fails after 2-4 weeks, consider:

1. Topical Therapy:

   • Nitroglycerin ointment (GTN): Decreases resting anal pressure
     • Healing rates: 25-50% 1
     • Common side effect: Headache (reported in up to 75% of patients) 2
   • Topical calcium channel blockers (e.g., diltiazem, nifedipine)
     • Similar effectiveness to GTN with fewer side effects 1

2. Botulinum Toxin Injection:

   • High cure rates (75-95%) 1
   • Low morbidity profile
   • Temporary sphincter relaxation for 2-3 months
   • Optimal injection location still controversial 1

Third-Line Treatment: Surgical Intervention

If non-operative management fails after 8 weeks 1:

• Lateral internal sphincterotomy (LIS):
  • Highest success rate (>95%) 3
  • Low recurrence rate (1-3%) 3
  • Rapid symptom relief 1, 4
  • Risk: Minor but sometimes permanent defects in continence 1

Comparative Effectiveness

• Surgery vs. Topical Nitroglycerin: In a comparative study, LIS showed 93% success rate compared to 50% with topical nitroglycerin 4
• Botulinum Toxin: Nearly as effective as surgery without significant adverse effects 3
• Topical Nitroglycerin: Effectiveness varies widely between studies, from showing significant benefit 5 to no benefit over placebo 6

Important Considerations and Pitfalls

1. Manual dilation is strongly discouraged as a treatment option 1

2. Risk assessment for incontinence should be performed before recommending surgery, especially in:

   • Women who have had vaginal deliveries
   • Elderly patients
   • Patients with pre-existing continence issues
   • Patients with inflammatory bowel disease

3. Recurrence risk:

   • Higher with medical therapy than surgical treatment
   • May require maintenance therapy in some patients

4. Chronic vs. acute fissures:

   • Acute fissures respond better to conservative treatment
   • Chronic fissures (>8 weeks with visible internal sphincter) more likely to require advanced interventions

By following this treatment algorithm, most patients with anal fissures can achieve healing and significant symptom relief, with surgery reserved for those who fail conservative and medical management.