What are the treatment options for anal fissures?

Treatment Options for Anal Fissures

The first-line treatment for anal fissures should be non-operative management, including dietary modifications with increased fiber (30-40g daily) and adequate water intake (at least 8 glasses), along with topical calcium channel blockers which are more effective than glyceryl trinitrate and have fewer side effects. 1

First-Line Conservative Management

Pain Management

• Topical anesthetics (lidocaine) combined with oral pain medications (paracetamol or ibuprofen) for immediate pain relief 1
• Integration of common pain killers when pain control is inadequate

Healing Agents

1. Topical Calcium Channel Blockers (First Choice)

   • Nifedipine or 2% diltiazem ointment applied twice daily for at least 6 weeks
   • Healing rates of 65-95%
   • Pain relief typically occurs after approximately 14 days
   • Fewer side effects than glyceryl trinitrate 1

2. Glyceryl Trinitrate (Second Choice)

   • Acts as a vasodilator to increase blood flow and reduce sphincter tone
   • Less effective than calcium channel blockers
   • Associated with more headaches and hypotension 1
   • Marginally better than placebo (48.9% vs. 35.5% healing) 2

Second-Line Treatment

Botulinum Toxin Injection

• Consider if no improvement after 4-6 weeks of conservative treatment
• High cure rates of 75-95% with low morbidity profile 1
• Equivalent efficacy to topical treatments with fewer adverse events 2

Surgical Management

Indicated for chronic fissures that don't respond to 8 weeks of conservative treatment 1

1. Lateral Internal Sphincterotomy (LIS)

   • Gold standard surgical treatment 3
   • Healing rates over 90%
   • Small risk (up to 3%) of minor continence issues
   • Reserved for persistent severe pain despite conservative treatment 1

2. Alternative Surgical Approaches

   • Fissurectomy: Revisited as an option for certain cases 4
   • Advancement flaps: Useful in patients where sphincter division is not suitable 4

Special Considerations

Atypical Fissures

• Require focused medical history and complete physical examination
• Consider laboratory tests based on suspected associated illness
• Imaging (endoscopy, CT, MRI, or endoanal ultrasound) should be considered if suspecting inflammatory bowel disease, cancer, or perianal sepsis 1

Anterior Fissures

• More common in women (10%) than men (1%)
• Associated with higher probability of underlying external anal sphincter defects
• Require greater caution with procedures that weaken the sphincter 1

Practices to Avoid

• Manual anal dilatation (strongly recommended against)
  • High risk of incontinence (temporary up to 30%, permanent up to 10%)
• Routine use of antibiotics (not recommended)
• Consider topical antibiotics only in cases of poor genital hygiene or reduced therapeutic compliance 1

Common Pitfalls in Management

• Assuming hemorrhoids are the cause without proper examination
• Failing to recognize atypical presentations
• Inadequate trial of conservative treatment
• Premature progression to invasive treatments
• Failure to identify associated pelvirectal disorders
• Not addressing dietary and lifestyle factors
• Discontinuing treatments prematurely 1

Treatment Algorithm

1. Start with conservative measures (fiber, water, sitz baths) + topical calcium channel blockers for 6 weeks
2. If inadequate response, consider botulinum toxin injection
3. If still unresolved after 8 weeks of conservative treatment, consider lateral internal sphincterotomy
4. For patients with high risk of incontinence, consider alternative surgical approaches like advancement flaps

Remember that adequate duration of therapy is essential (at least 6 weeks) to avoid premature discontinuation of treatment, as late recurrence of fissures is common, occurring in approximately 50% of initially healed cases 1, 2.