What is the treatment for rectal fissures?

Treatment for Rectal Fissures

The first-line treatment for rectal fissures should be conservative management, including fiber supplementation, adequate fluid intake, sitz baths, and topical analgesics, with approximately 50% of all anal fissures healing with this approach alone. 1

Initial Conservative Management (First 2 Weeks)

• Increase fiber intake through diet or supplements to soften stools 1, 2
• Ensure adequate fluid intake to prevent constipation 1, 2
• Take warm sitz baths to relax the internal anal sphincter 1, 2
• Apply topical analgesics (such as lidocaine) for pain control 1, 2
• Consider stool softeners if dietary changes are insufficient 2
• Pain control is essential as it helps reduce reflex spasm of the anal sphincter, enhancing healing 1

Second-Line Treatment (If No Improvement After 2 Weeks)

• Topical calcium channel blockers (diltiazem or nifedipine) should be considered as first-line topical treatment with healing rates of 65-95% and minimal side effects 1
• Glyceryl trinitrate ointment is an alternative with healing rates of 25-50%, though headaches are a common side effect 2
• Topical antibiotics (metronidazole) may be considered in cases of poor genital hygiene, with one study showing improved healing rates when added to lidocaine 1

Third-Line Treatment (For Persistent Fissures)

• Botulinum toxin injection has high cure rates of 75-95% with low morbidity by causing temporary sphincter relaxation 1
• Surgical options (lateral internal sphincterotomy) should only be considered if non-operative management fails after 8 weeks 1, 3

Important Considerations

• Most acute fissures heal within 10-14 days with conservative management 4
• Chronic fissures persist longer than 8-12 weeks 3
• Manual dilatation should be avoided due to high risk of temporary and permanent incontinence 1, 2
• Atypical fissure locations (not posterior midline) require evaluation for underlying conditions such as Crohn's disease or inflammatory bowel disease 2
• Signs of chronicity include sentinel tag, hypertrophied papilla, fibrosis, and visualization of bare internal sphincter muscle 2

Treatment Algorithm

1. Start with conservative management for 2 weeks (fiber, fluids, sitz baths, topical analgesics) 1
2. If no improvement after 2 weeks, add topical calcium channel blocker 1
3. If still no improvement, consider botulinum toxin injection 1
4. Consider surgical options only if non-operative management fails after 8 weeks 1, 5

Special Considerations for Different Age Groups

• In infants, mild anal fissures typically heal within 10-14 days with conservative management alone 4
• In children, surgical interventions should be avoided for acute fissures 2
• In adults, lateral internal sphincterotomy is the surgical management of choice for chronic and refractory acute fissures 3, 5

Common Pitfalls to Avoid

• Neglecting pain control, which is essential for breaking the cycle of pain, spasm, and ischemia 1
• Rushing to surgical options before adequate trial of conservative and topical treatments 1, 5
• Failing to recognize atypical fissures that may indicate underlying disease 2
• Using manual dilatation, which carries high risk of incontinence 1, 2