What are the treatment options for anal fissures?

Treatment Options for Anal Fissures

Conservative management should be the first-line treatment for anal fissures, with about 50% healing within 10-14 days through fiber supplementation, adequate fluid intake, sitz baths, and topical analgesics. 1, 2

First-Line Treatment: Conservative Management

• Conservative care is the initial approach for most anal fissures and includes:

  • Fiber supplementation to soften stools 1, 2
  • Ensuring adequate fluid intake 1, 2
  • Warm sitz baths to relax the internal anal sphincter 2
  • Topical analgesics for pain control 2

• This approach addresses the pathogenesis factors of mechanical trauma, sphincter spasm, and ischemia 3

• Acute fissures are more likely to heal with conservative care than chronic ones 1

Second-Line Pharmacological Treatments

When conservative management fails after 2 weeks, consider these pharmacological options:

• Topical calcium channel blockers (diltiazem or nifedipine)

  • Healing rates of 65-95% 2
  • Recommended for at least 6 weeks 2
  • Pain relief typically occurs after 14 days 2
  • Currently preferred over nitroglycerin due to fewer side effects 4

• Glyceryl trinitrate (GTN) ointment

  • Healing rates of 25-50% 2
  • Common side effect: headaches (up to 84% of patients) 5

• Botulinum toxin injection

  • High cure rates of 75-95% with low morbidity 1, 2
  • Optimal injection location remains controversial 1
  • Minor incontinence for flatus and soiling reported in up to 12% of patients 5

Surgical Options

• Lateral internal sphincterotomy (LIS)

  • Gold standard surgical procedure for chronic anal fissures 2, 6
  • Indicated when:
    • Chronic fissures don't respond to 8 weeks of non-operative management 2
    • Acute fissures with severe pain 2
    • Conservative care fails 1
  • Caution: Associated with risk of permanent minor sphincter impairment 1

• Fissurectomy combined with anoplasty

  • Preferred in some countries to reduce incontinence risk 3

• Manual dilatation

  • Strongly discouraged due to high risk of incontinence 2

Important Diagnostic Considerations

• Most anal fissures occur in the midline, usually posteriorly 1

• Atypical locations (off midline) require evaluation for underlying conditions such as:

  • Crohn's disease
  • HIV/AIDS
  • Ulcerative colitis
  • Tuberculosis
  • Syphilis
  • Leukemia
  • Cancer 1, 2

• Signs of chronicity include:

  • Sentinel tag
  • Hypertrophied papilla
  • Fibrosis
  • Visualization of bare internal sphincter muscle at the fissure base 1, 2

Treatment Algorithm

1. Start with conservative management for all acute fissures and those with tolerable pain 1, 2
2. If no improvement after 2 weeks, add topical calcium channel blockers 2
3. If still no improvement after 6 weeks, consider botulinum toxin injection 1, 2
4. Consider surgery for:
   • Chronic fissures unresponsive to 8 weeks of medical management
   • Severe pain requiring immediate action
   • Failed conservative and pharmacological treatments 1, 2

Common Pitfalls to Avoid

• Failing to identify atypical fissures that may indicate underlying disease 1, 2
• Using manual dilatation, which carries high risk of incontinence 2
• Rushing to surgery before adequate trial of conservative and pharmacological treatments 2
• Overlooking the possibility of coexisting hemorrhoids (present in 20% of fissure patients) 4