What are the treatment options for anal fissures?

Anal Fissure Treatment Options

The treatment of anal fissures should follow a stepwise approach, beginning with conservative measures, progressing to topical medications (with calcium channel blockers being preferred over nitrates), then botulinum toxin injections, and finally surgical intervention with lateral internal sphincterotomy as the gold standard for refractory cases. 1

Diagnosis and Clinical Presentation

• Anal fissures typically present with:

  • Bright red bleeding (71.4% of patients) 1
  • Severe pain during and after defecation
  • Visible tear in the anal canal, most commonly in the posterior midline (90%)

• Warning signs requiring further investigation:

  • Lateral or multiple fissures may indicate underlying conditions such as inflammatory bowel disease, STIs, anorectal cancer, tuberculosis, or leukemia 1
  • Atypical fissures require more extensive evaluation

Treatment Algorithm

First-Line: Conservative Management

1. Dietary modifications:

   • Increase fiber intake (goal: 30-40g daily)
   • Ensure adequate hydration (at least 8 glasses of water daily)
   • Use of stool softeners to prevent constipation 1

2. Symptomatic relief:

   • Warm sitz baths to promote internal anal sphincter relaxation
   • Topical moisturizing agents (petroleum jelly, zinc oxide) as protective barriers
   • Oral analgesics (acetaminophen, ibuprofen) for breakthrough pain 1

Second-Line: Topical Medications

1. Calcium channel blockers:

   • 2% diltiazem ointment is preferred due to higher efficacy (65-95% healing rates) and fewer side effects 1
   • Apply 2-3 times daily for 4-8 weeks

2. Topical nitrates:

   • 0.4% glyceryl trinitrate ointment
   • Less preferred due to higher incidence of headaches 2
   • Success rates of 50-90% 2

Third-Line: Botulinum Toxin Injection

• Consider if no improvement after 4-6 weeks of conservative treatment
• High cure rates of 75-95% with low morbidity 1
• Effects typically last 3-6 months; may require repeat injections
• Nearly as effective as surgery without significant adverse effects 3

Fourth-Line: Surgical Treatment

• Lateral Internal Sphincterotomy (LIS):

  • Gold standard surgical treatment with success rates >95% 1, 4
  • Low recurrence rate (1-3%) 3
  • Consider as last resort due to risk of permanent minor sphincter impairment 1
  • Most effective long-term treatment option 5

• Fissurectomy with anoplasty:

  • Alternative surgical approach preferred in some countries to reduce incontinence risk 5

Treatment Monitoring and Failure

• Assess response at 2-week intervals initially
• Consider treatment failure if no improvement after 8 weeks of conservative management 1
• Chronic fissures (lasting >6 weeks with visible muscle fibers) may require more aggressive treatment 6

Common Pitfalls to Avoid

1. Misdiagnosing hemorrhoids as the cause of anorectal symptoms
2. Failing to recognize atypical presentations that may indicate serious underlying conditions
3. Inadequate trial of conservative treatment before progressing to invasive options
4. Discontinuing treatments prematurely before healing can occur
5. Not addressing dietary and lifestyle factors contributing to recurrence 1
6. Manual anal dilatation is no longer recommended due to high risk of incontinence 5

Special Considerations

• Risk of incontinence after LIS may have been overemphasized in the past 2
• Treatment should be tailored based on factors such as:
  • Chronicity of the fissure
  • Severity of symptoms
  • Patient's risk factors for incontinence
  • Previous treatment failures 1, 3