From the Guidelines
The best treatment for a severely symptomatic posterior anal fissure is lateral internal sphincterotomy after 8 weeks of non-operative management.
Treatment Approach
- Non-operative management should be attempted for 6-8 weeks, including dietary and lifestyle modifications, and medical therapy, before considering surgical treatment 1.
- If non-operative management fails, lateral internal sphincterotomy is the preferred surgical technique due to its high healing rate of over 90%, lower recurrence rate, and higher patient satisfaction 1.
- Both open and closed lateral internal sphincterotomy have similar results, but open lateral internal sphincterotomy may be associated with higher post-operative pain and delayed wound healing at 1 year 1.
Key Considerations
- Surgical treatment is not recommended for acute anal fissures, but rather for chronic cases that are non-responsive to non-operative management 1.
- Fissurectomy and posterior sphincterotomy are not preferred techniques due to lower healing rates, higher post-operative pain, and increased risk of fecal incontinence compared to lateral internal sphincterotomy 1.
From the Research
Treatment Options for Severely Symptomatic Posterior Anal Fissure
- Medical treatment is non-specific, aimed at softening the stool and facilitating regular bowel movements, resulting in healing of almost 50% of acute anal fissures 2
- Specific medical treatment can be offered to reversibly decrease hypertonic sphincter spasm if non-specific medical treatment fails 2
- Surgery remains the most effective long-term treatment and should be offered for cases of chronic or complicated anal fissure, as well as for acute anal fissure with severe pain or for recurrent fissure despite optimal medical treatment 2, 3
Surgical Treatment
- Lateral internal sphincterotomy (LIS) is the best-evaluated technique and remains the gold standard in English-speaking countries 2, 4, 5
- Fissurectomy with posterior midline sphincterotomy and anoplasty (FPSA) is a surgical technique that has been successfully used to treat chronic anal fissures 6
- Other techniques, such as calibrated sphincterotomy and sphincteroplasty, have been described to reduce the risk of incontinence 2
Considerations for Treatment
- The risk of recurrent fissure remains high if the causative factors persist 2
- The choice of treatment should take into account the patient's willingness to accept the potential risk of fecal incontinence 3, 4
- Non-surgical therapies, such as topical sphincter relaxants or botulin toxin injection, may be considered as a first-line treatment for patients with severe, unrelenting pain and no incontinence risk factors 3, 4