What are the treatment options for anal fissure?

Anal Fissure Treatment Options

Non-operative management should be the first-line treatment for anal fissures, including dietary modifications, sitz baths, and topical agents, with surgical intervention reserved only for chronic fissures that fail to respond after 8 weeks of conservative treatment. 1, 2

Initial Management for Acute Anal Fissures

Conservative Measures (First-Line)

• Dietary and lifestyle modifications:

  • Increased fiber intake (supplements or high-fiber diet)
  • Adequate fluid intake
  • Stool softeners and bulk-forming laxatives 1, 2

• Symptomatic relief:

  • Warm sitz baths (promote relaxation of internal anal sphincter)
  • Topical analgesics for pain control 1, 2
  • Topical antibiotics may be considered in cases of poor genital hygiene 1

Approximately 50% of acute anal fissures will heal within 10-14 days with these conservative measures alone 1.

Medical Therapy for Persistent Fissures

If conservative measures fail to provide relief after 2-4 weeks, consider adding:

Chemical Sphincterotomy Options

• Topical calcium channel blockers (e.g., diltiazem, nifedipine):

  • Reduce internal anal sphincter tone
  • Increase local blood flow
  • Fewer side effects than nitrates 2, 3

• Topical nitrates (e.g., glyceryl trinitrate):

  • Promote vasodilation and increase blood flow
  • Reduce sphincter tone
  • Note: Headaches are a common side effect limiting compliance 1, 4

• Botulinum toxin injection:

  • Causes temporary paralysis of anal sphincter for 2-3 months
  • High success rates
  • Reserved for fissures that don't respond to topical treatments
  • Minimal risk of temporary incontinence 1, 2, 3

Surgical Management for Chronic Fissures

Surgery should only be considered after 8 weeks of failed non-operative management 1, 2

• Lateral internal sphincterotomy (LIS):

  • Gold standard surgical procedure
  • Success rates >95% with low recurrence (1-3%)
  • Involves partial division of internal anal sphincter
  • Caution: Risk of permanent minor fecal incontinence in 1-10% of patients 2, 4, 5

• Fissurectomy:

  • Alternative surgical option
  • May be considered when sphincter preservation is critical 6

Important Considerations

• Manual anal dilatation is strongly discouraged due to risk of uncontrolled sphincter damage 1

• Atypical fissures (lateral, multiple, or non-healing) require further investigation to rule out:

  • Inflammatory bowel disease
  • Sexually transmitted infections
  • Anorectal cancer
  • Tuberculosis 1, 2

• Chronic fissures (present >6 weeks with visible sphincter fibers) are more resistant to conservative management and more likely to require medical or surgical intervention 6

Treatment Algorithm

1. Acute fissure (< 6 weeks):

   • Start with conservative measures (fiber, fluids, sitz baths)
   • Add topical analgesics if pain control inadequate
   • Continue for 2-4 weeks

2. If no improvement after 2-4 weeks:

   • Add topical calcium channel blockers or nitrates
   • Continue for additional 4 weeks

3. If still no improvement after 8 weeks (chronic fissure):

   • Consider botulinum toxin injection
   • If fails or contraindicated, consider lateral internal sphincterotomy

The treatment approach should balance effective healing with preservation of anal sphincter function to minimize the risk of incontinence, which can significantly impact quality of life 2, 4.