What are the treatment options for anal fissures?

Treatment Options for Anal Fissures

The most effective treatment approach for anal fissures follows a stepwise algorithm, beginning with conservative measures, progressing to topical medications, then botulinum toxin injections, and finally surgical intervention for refractory cases. 1

Diagnosis and Initial Assessment

• Typical presentation: Bright red bleeding (71.4% of patients), severe pain with defecation 1
• Location: 90% posterior midline; anterior fissures more common in women (10%) than men (1%) 1
• Warning signs requiring further investigation:
  • Lateral or multiple fissures (may indicate inflammatory bowel disease, STIs, anorectal cancer, tuberculosis, or leukemia) 1
  • Non-healing fissures despite appropriate treatment

Treatment Algorithm

1. Conservative Management (First-Line)

• Dietary modifications:
  • Increase fiber intake (goal: 30-40g daily)
  • Ensure adequate hydration (at least 8 glasses of water daily) 1
  • Stool softeners to prevent constipation
• Symptomatic relief:
  • Warm sitz baths (promotes internal anal sphincter relaxation)
  • Topical moisturizing agents (petroleum jelly, zinc oxide) 1
  • Oral analgesics for breakthrough pain (acetaminophen, ibuprofen)

2. Topical Medications (If no improvement after 2 weeks)

• Topical calcium channel blockers:
  • 2% diltiazem ointment (preferred due to higher efficacy and fewer side effects)
  • Healing rates: 65-95% 1
• Assessment schedule:
  • Evaluate response every 2 weeks initially
  • Consider treatment failure if no improvement after 8 weeks 1

3. Botulinum Toxin Injection (If no improvement after 4-6 weeks of conservative treatment)

• Efficacy:
  • High cure rates: 75-95%
  • Low morbidity profile 1
• Important considerations:
  • Effects typically last 3-6 months
  • May require repeat injections 1
  • Safety profile: FDA label indicates no significant safety concerns for adults 2

4. Surgical Treatment (Last Resort)

• Lateral Internal Sphincterotomy (LIS):
  • Gold standard surgical treatment
  • Rapid and effective healing (>95% success rate) 1, 3
  • Should be considered only after failure of less invasive approaches
• Risk consideration:
  • Carries risk of permanent minor sphincter impairment 1
  • Risk of fecal incontinence (1-3%) 3

Treatment Pitfalls to Avoid

• Misdiagnosing hemorrhoids as the cause without proper examination
• Failing to recognize atypical presentations requiring further investigation
• Manual anal dilatation (no longer recommended) 4
• Inadequate trial of conservative treatment before progressing to invasive options
• Premature discontinuation of treatments 1
• Not addressing underlying dietary and lifestyle factors

Special Considerations

• For severe or complicated cases, surgical intervention may be considered earlier in the treatment algorithm 4
• Fissurectomy combined with anoplasty is preferred in some clinical practices as an alternative to LIS to reduce incontinence risk 4
• The use of LigaSure Small Jaw device has been explored as an alternative surgical approach, though more evidence is needed 5

Monitoring and Follow-up

• Assess response to conservative treatment every 2 weeks
• Consider treatment failure if no improvement after 8 weeks of conservative management 1
• Monitor for recurrence after healing, as anal fissures may be chronic and recur depending on sphincteric features 3