What are the management options for anal fissures in children?

Management of Anal Fissures in Children

For children with anal fissures, conservative management should be the first-line approach, including increased fiber intake, adequate hydration, stool softeners, and sitz baths, with pharmacological treatments such as topical calcium channel blockers considered for persistent cases before surgical options are explored. 1

Conservative Management (First-Line)

Dietary and Lifestyle Modifications

• Increased fiber intake (aim for age-appropriate amounts) and adequate water consumption to soften stool 1
• Stool softeners such as docusate sodium:
  • Children 2-12 years: 1 softgel daily 2
  • Children 12+ years: 1-3 softgels daily (can be divided doses) 2
  • Children under 2 years: consult physician 2
• Warm sitz baths for pain relief 1
• Topical moisturizers such as petroleum jelly or zinc oxide to provide a protective barrier 1

Topical Medications

• Topical anesthetics (lidocaine) for pain management 1
• Topical calcium channel blockers (nifedipine or 2% diltiazem ointment) applied twice daily for at least 6 weeks - these reduce internal anal sphincter tone and increase local blood flow 1
• Glyceryl trinitrate (nitroglycerin) ointment at 0.2% concentration has shown efficacy in pediatric patients with 77% symptomatic relief and 60% healing rate compared to 54% and 32.8% in control groups 3

Second-Line Treatments

Botulinum Toxin Injection

• Effective for chronic anal fissures in children who fail conservative management 4
• Dosage recommendations:
  • Children under 2 years: 1.25 U x 2 4
  • Children over 2 years: 2.5 U x 2 4
• Injections are administered into the external sphincter on both sides of the fissure under light anesthesia 4
• Results show quick pain relief with 11 of 13 children becoming symptom-free within one week in a pilot study 4
• Recurrences may occur after 3-30 months (when pharmacological effect recedes) but can be treated with additional injections 4

Surgical Interventions (Last Resort)

• Reserved for cases that fail medical therapy 1, 5
• Lateral internal sphincterotomy (LIS) has healing rates over 90% but carries small risk of continence issues 1
• Special caution needed with anterior fissures, especially in female patients, due to higher risk of incontinence 1

Treatment Algorithm for Pediatric Anal Fissures

1. Start with conservative management:

   • Dietary modifications (fiber, hydration)
   • Stool softeners (docusate sodium) at age-appropriate doses
   • Sitz baths and topical moisturizers
   • Topical anesthetics for pain relief

2. If no improvement after 2-4 weeks, add:

   • Topical calcium channel blockers (nifedipine/diltiazem) OR
   • Glyceryl trinitrate ointment (0.2%)

3. For persistent fissures after 6-8 weeks of medical therapy:

   • Consider botulinum toxin injection under light anesthesia

4. For refractory cases only:

   • Surgical consultation for possible lateral internal sphincterotomy

Common Pitfalls and Considerations

• Avoid premature progression to invasive treatments before adequate trial of conservative management 1
• Don't discontinue treatments prematurely - healing may take 6-8 weeks 1
• Recognize recurrence risk - particularly with botulinum toxin as effects wear off after 3-4 months 4
• Evaluate for underlying conditions in persistent cases, such as Crohn's disease 1
• Maintain long-term dietary modifications to prevent recurrence, especially in children prone to constipation 1, 4
• Avoid manual dilation of the anus (strong recommendation based on moderate-quality evidence) 1

The evidence strongly supports a stepwise approach, starting with conservative measures before progressing to more invasive options. While surgical sphincterotomy remains the most effective treatment for chronic fissures in adults 5, the risk-benefit profile favors exhausting medical options first in the pediatric population.