What is the recommended approach for the evaluation and treatment of anal fissures?

Evaluation and Treatment of Anal Fissures

The recommended approach for anal fissure management begins with conservative treatment including stool softeners, topical calcium channel blockers (particularly 2% diltiazem), dietary modifications, and sitz baths, progressing to botulinum toxin injections if no improvement occurs after 4-6 weeks, with surgical intervention reserved for chronic or refractory cases. 1

Diagnosis and Evaluation

Clinical Presentation

• Pain during and after defecation (typically more severe than with hemorrhoids)
• Bright red and scanty bleeding (present in 71.4% of patients) 1
• Anal spasm and fear of defecation

Physical Examination

• Most fissures (90%) are located posteriorly in the midline
• 10% of women and 1% of men have anterior fissures 1
• Warning signs requiring further investigation:
  • Lateral or multiple fissures
  • Atypical appearance or non-healing fissures
  • These may indicate underlying conditions such as inflammatory bowel disease, sexually transmitted infections, anorectal cancer, tuberculosis, or leukemia 1

Treatment Algorithm

First-Line: Conservative Management

1. Stool softeners and dietary modifications:

   • Increase fiber intake (goal: 30-40g daily)
   • Ensure adequate hydration (at least 8 glasses of water daily)
   • Consider bulk-forming laxatives 1

2. Topical treatments:

   • 2% diltiazem ointment (preferred first-line pharmacological therapy)
     • Higher efficacy and fewer side effects than nitrates
     • Healing rates of 65-95% 1
     • Studies show it's effective even in patients who failed GTN therapy 2
   • Moisturizing agents (petroleum jelly or zinc oxide) as protective barriers 1

3. Pain management:

   • Warm sitz baths for symptomatic relief
   • Oral analgesics (acetaminophen, ibuprofen) for breakthrough pain 1

Second-Line: Botulinum Toxin Injection

• Consider if no improvement after 4-6 weeks of conservative treatment
• High cure rates (75-95%) with low morbidity
• Effects typically last 3-6 months; may require repeat injections 1

Third-Line: Surgical Treatment

• Lateral Internal Sphincterotomy (LIS):
  • Gold standard surgical treatment with rapid and effective results
  • Reserved for chronic, complicated, or recurrent fissures despite optimal medical treatment
  • High success rate but carries risk of permanent minor sphincter impairment 1, 3
• Fissurectomy with anoplasty:
  • Preferred in some countries (including France) to reduce incontinence risk 3

Treatment Monitoring and Assessment

• Assess response at 2-week intervals initially
• Consider treatment failure if no improvement after 8 weeks of conservative management 1
• For recurrences after successful treatment, repeat the conservative approach before considering surgery 4, 2

Common Pitfalls to Avoid

1. Misdiagnosing hemorrhoids as the cause without proper examination
2. Failing to recognize atypical presentations requiring further investigation
3. Using manual anal dilatation (no longer recommended) 3
4. Inadequate trial of conservative treatment before invasive approaches
5. Premature discontinuation of treatments
6. Not addressing dietary and lifestyle factors 1

Evidence Strength and Considerations

• Topical diltiazem has shown success rates of 48-75% in studies, even in patients who failed GTN therapy 4, 2
• While GTN was historically used, it has higher rates of side effects (particularly headaches) compared to diltiazem 5, 4
• Surgical approaches remain the most effective long-term treatment but should be reserved for cases where conservative management fails due to the risk of incontinence 1, 3