What is the treatment for an anal fissure?

Treatment for Anal Fissure

The first-line treatment for anal fissures is conservative management, which includes fiber supplementation, adequate fluid intake, sitz baths, and topical analgesics, with approximately 50% of acute anal fissures healing within 10-14 days using these measures. 1

Initial Conservative Management

• Increase fiber intake through diet or supplements to soften stools and reduce pain during defecation 2, 1
• Ensure adequate fluid intake to maintain soft stool consistency 2
• Take warm sitz baths to relax the internal anal sphincter 2, 1
• Use topical analgesics (like lidocaine) for pain control 3, 1
• Consider stool softeners if dietary changes are insufficient 2

Pain Management

• Pain control is essential as it reduces reflex spasm of the anal sphincter, enhancing healing 2
• For inadequate pain control, integrate topical anesthetics with common pain killers like paracetamol or ibuprofen 3
• Pain relief typically occurs within 14 days of starting appropriate treatment 2

Second-Line Pharmacological Treatments

If conservative management fails after 2 weeks, consider:

• Topical calcium channel blockers (diltiazem or nifedipine) with healing rates of 65-95% 2, 1
• Glyceryl trinitrate ointment (0.2%) with healing rates of 25-50%, though headaches are a common side effect 2, 1, 4
• Botulinum toxin injection with high cure rates of 75-95% and low morbidity 1, 5

Surgical Management

• Surgical treatment is not recommended for acute anal fissures 3
• Lateral internal sphincterotomy should be reserved for chronic fissures that are non-responsive after 8 weeks of conservative management 3, 1
• Manual dilatation is strongly discouraged due to high risk of incontinence (temporary incontinence rates can reach 30% and permanent rates up to 10%) 3, 2

Special Considerations

• Topical antibiotics may be considered in cases of poor genital hygiene 3
• Atypical fissure locations (not in the posterior midline) require evaluation for underlying conditions like Crohn's disease, HIV/AIDS, or cancer 2, 1
• Signs of chronicity include sentinel tag, hypertrophied papilla, fibrosis, and visualization of bare internal sphincter muscle 2, 1

Treatment Algorithm

1. First 2 weeks: Conservative management (fiber, fluids, sitz baths, topical analgesics)
2. If persistent after 2 weeks: Add topical calcium channel blockers or glyceryl trinitrate
3. If persistent after 6 weeks: Consider botulinum toxin injection
4. If persistent after 8 weeks: Consider surgical referral for lateral internal sphincterotomy

Common Pitfalls to Avoid

• Rushing to surgical treatment for acute fissures, which should be avoided 3
• Using manual dilatation, which has high incontinence risk 3
• Failing to identify atypical fissures that may indicate underlying disease 2, 1
• Inadequate pain control, which can lead to continued sphincter spasm and delayed healing 3, 2
• Discontinuing treatment too early, as recurrence rates can be high (up to 67% in some studies) 6