What are the treatment options for anal fissures?

Treatment Options for Anal Fissures

Topical calcium channel blockers are the first-line treatment for anal fissures, with healing rates of 65-95% and fewer side effects than nitrates. 1

Treatment Algorithm

First-Line Treatment:

1. Conservative Management

   • Dietary modifications: Increase fiber (30-40g daily) and water intake (at least 8 glasses daily) 1
   • Stool softeners to prevent constipation 2
   • Warm sitz baths for symptomatic relief 1
   • Topical calcium channel blockers (e.g., 2% diltiazem ointment) 1
     • Higher efficacy and fewer side effects than nitrates
     • Healing rates of 65-95%

2. Pain Management

   • Acetaminophen or ibuprofen for breakthrough pain 1
   • Topical anesthetics (lidocaine) before bowel movements 1
   • Moisturizing agents such as petroleum jelly or zinc oxide 1

Second-Line Treatment:

If no improvement after 4-6 weeks of conservative treatment:

• Botulinum Toxin Injection
  • High cure rates (75-95%) 2, 1
  • Low morbidity profile 2
  • Effects typically last 3-6 months and may require repeat injections 1
  • Optimal injection location (internal vs. external sphincter) remains controversial 2

Third-Line Treatment:

If all other treatments fail:

• Lateral Internal Sphincterotomy (LIS)
  • High success rate but carries risk of permanent minor sphincter impairment 2, 1
  • Works rapidly and effectively 2
  • Considered the gold standard surgical treatment in English-speaking countries 3
  • Alternative surgical approaches include fissurectomy combined with anoplasty (preferred in France) 3

Important Clinical Considerations

Diagnostic Pearls

• 90% of anal fissures are located posteriorly in the midline 1
• Anterior fissures occur in 10% of women versus 1% of men 1
• Bright red and scanty bleeding is present in 71.4% of patients 1

Red Flags

• Lateral or multiple fissures should raise suspicion for underlying conditions:
  • Inflammatory bowel disease
  • Sexually transmitted infections
  • Anorectal cancer
  • Tuberculosis
  • Leukemia 1

Treatment Efficacy and Controversies

The efficacy of glyceryl trinitrate (GTN) ointment is controversial. While some studies show healing rates up to 70% 4, others demonstrate no significant benefit compared to placebo 5. Additionally, GTN has a high recurrence rate (67% at 9 months in chronic fissures) 6 and frequently causes headaches as a side effect (77% of patients) 6.

The American Gastroenterological Association notes that topical therapy and botulinum toxin injection represent efforts to achieve prompt but temporary sphincter relaxation, combining the safety of nonoperative treatment with the high cure rate and rapid effect of lateral internal sphincterotomy 2.

Common Pitfalls to Avoid

1. Assuming hemorrhoids are the cause of anorectal symptoms without proper examination 1
2. Failing to recognize atypical presentations that may indicate underlying disease 1
3. Manual anal dilatation (strongly discouraged due to risk of uncontrolled sphincter damage) 1
4. Inadequate trial of conservative treatment before progressing to invasive options 1
5. Discontinuing treatments prematurely 1

Follow-up Recommendations

• Assess healing at 2-week intervals to monitor progress 1
• Consider treatment failure if no improvement after 8 weeks of conservative management 1
• Further investigation for atypical or non-healing fissures 1