What is the treatment for anal fissure?

Treatment of Anal Fissure

For anal fissure treatment, non-operative management should be the first-line approach, including dietary changes with increased fiber and water intake, while surgical intervention should be reserved for chronic fissures that don't respond to 8 weeks of conservative treatment. 1, 2

Initial Management of Acute Anal Fissure

Conservative Treatment

• Dietary and lifestyle modifications:
  • Increase fiber intake (30-40g daily) and water consumption (at least 8 glasses) 2
  • Consider bulk-forming laxatives and stool softeners 2
  • Apply moisturizing agents like petroleum jelly or zinc oxide as protective barriers 2

Pain Management

• Topical anesthetics (lidocaine) for pain relief 2
• Warm sitz baths to relieve discomfort 2
• Integration of common pain killers when pain control is inadequate 1

Pharmacological Treatment

• First-line pharmacological options:

  • Topical calcium channel blockers (2% diltiazem or nifedipine ointment applied twice daily for 6 weeks)

    • Healing rates: 65-95% 2
    • Mechanism: Reduces internal anal sphincter tone and increases local blood flow

  • Glyceryl trinitrate (GTN) ointment

    • Acts as a vasodilator 2
    • Less effective than calcium channel blockers and associated with more headaches 2

• Second-line pharmacological option:

  • Botulinum toxin injection
    • High cure rates (75-95%) with low morbidity 2
    • Consider if no improvement after 4-6 weeks of conservative treatment 2

Antibiotics

• Routine use of antibiotics is not recommended 1
• Consider topical antibiotics only in cases of poor genital hygiene or reduced therapeutic compliance 1, 2

Management of Chronic or Non-responsive Anal Fissure

When to Consider Surgical Treatment

• After failure of non-operative management for 8 weeks 1
• For chronic or complicated anal fissures 3
• For acute fissures with severe pain 3
• For recurrent fissures despite optimal medical treatment 3

Surgical Options

• Lateral internal sphincterotomy (LIS):

  • Gold standard surgical treatment in many countries 3, 4
  • Healing rates over 90% 2
  • Caution: Small risk (up to 3%) of minor continence issues 2

• Fissurectomy with anoplasty:

  • Preferred in some countries (e.g., France) to reduce incontinence risk 3

• Techniques to avoid:

  • Manual dilatation of the anus (strongly recommended against) 1, 2
  • Forcible uncalibrated anal dilatation 3

Special Considerations

Atypical Fissures

• For atypical fissures, consider:
  • Focused medical history and complete physical examination 1
  • Laboratory tests based on suspected associated illness 1
  • Imaging (endoscopy, CT, MRI, or endoanal ultrasound) if suspecting inflammatory bowel disease, cancer, or perianal sepsis 1

Anterior Fissures

• Require special caution, especially in women 2
• Higher risk of incontinence with sphincter-weakening procedures 2
• Higher association with external anal sphincter defects 2

Common Pitfalls to Avoid

• Misdiagnosing hemorrhoids as the cause without proper examination 2
• Failing to recognize atypical presentations 2
• Inadequate trial of conservative treatment before surgery 2
• Premature progression to invasive treatments 2
• Not addressing dietary and lifestyle factors 2
• Discontinuing treatments prematurely 2

Remember that while surgical treatment has the highest long-term success rate, the potential complications of incontinence make conservative management the preferred initial approach for most patients with anal fissures.