What are the initial management options for anal fissures?

Management of Anal Fissures

Initial management of anal fissures should be non-operative, including dietary and lifestyle changes with increased fiber and water intake, along with topical calcium channel blockers as first-line treatment. 1, 2

Non-Operative Management (First-Line Approach)

Dietary and Lifestyle Modifications

• Increase fiber intake (30-40g daily) through diet or supplements 2
• Ensure adequate water consumption (at least 8 glasses daily) 2
• Use stool softeners and bulk-forming laxatives to prevent constipation 1
• Avoid prolonged straining during bowel movements

Topical Treatments

1. Calcium channel blockers (first choice):

   • Nifedipine or 2% diltiazem ointment applied twice daily for at least 6 weeks 2
   • Associated with healing rates of 65-95% 2
   • Pain relief typically occurs after approximately 14 days 2
   • Fewer side effects than nitrates 2, 3

2. Warm sitz baths:

   • 2-3 times daily for 10-15 minutes 2
   • Provides symptom relief through improved hygiene and reduced pain 2

3. Pain management:

   • Topical anesthetics (lidocaine) 2
   • Oral pain medications (paracetamol or ibuprofen) as needed 2

Second-Line Treatments (If No Improvement After 4-6 Weeks)

Botulinum Toxin Injection

• High cure rates of 75-95% with low morbidity profile 2
• Nearly as effective as surgery without significant adverse effects 4
• Temporary decrease of anal pressures that allows fissures to heal 4
• Consider if no improvement after 4-6 weeks of conservative treatment 2

Topical Nitrates

• Glyceryl trinitrate (GTN) ointment is marginally better than placebo (48.9% vs. 35.5% healing) 5
• Less effective than calcium channel blockers (60-70% healing rate) 4
• Common side effect: headache 4, 3
• High recurrence rate (around 50% of initially healed fissures) 5

Surgical Management (Reserved for Treatment Failures)

• Consider only after 8 weeks of failed conservative treatment 2
• Lateral internal sphincterotomy (LIS) is the gold standard surgical procedure 2, 3
• Healing rates over 90% with LIS 2, 3
• Risk of minor continence issues (3-4.4%) 2, 3
• Strongly avoid manual anal dilatation due to high risk of incontinence (temporary incontinence up to 30%, permanent up to 10%) 1, 2

Special Considerations

Atypical Fissures

• Lateral, multiple, or unusually large fissures may indicate underlying conditions 1
• Consider additional investigations if atypical presentation:
  • Focused medical history and complete physical examination 1, 2
  • Laboratory tests based on suspected associated illness 1, 2
  • Imaging (endoscopy, CT, MRI, or endoanal ultrasound) if suspecting inflammatory bowel disease, cancer, or perianal sepsis 1, 2

Anterior Fissures

• Higher probability of underlying external anal sphincter defects 2
• Require greater caution with sphincter-weakening procedures 2
• More common in women (10%) than men (1%) 1

Common Pitfalls to Avoid

1. Premature progression to invasive treatments before adequate trial of conservative management
2. Failing to recognize atypical presentations that may indicate other conditions
3. Discontinuing treatments prematurely (calcium channel blockers need at least 6 weeks)
4. Using manual anal dilatation (strongly contraindicated) 1, 2
5. Not addressing dietary and lifestyle factors that contribute to recurrence
6. Assuming hemorrhoids are the cause of symptoms without proper examination (20% of patients with hemorrhoids also have anal fissures) 6

Treatment Algorithm

1. Start with dietary changes (fiber, water) + sitz baths + topical calcium channel blocker for 6 weeks
2. If no improvement, consider botulinum toxin injection
3. If still no improvement after 8 weeks of conservative treatment, consider surgical referral for lateral internal sphincterotomy
4. For atypical fissures, investigate for underlying conditions before proceeding with standard treatment