What are the treatment options for anal fissures?

Treatment of Anal Fissures

First-Line Treatment: Conservative Management

Start all patients with anal fissures on conservative management for 2 weeks, as approximately 50% will heal with these measures alone. 1

Conservative treatment includes:

• Fiber supplementation to soften stools and reduce straining 1
• Adequate fluid intake to maintain soft stool consistency 1
• Warm sitz baths 2-3 times daily to relax the internal anal sphincter 1
• Topical analgesics (lidocaine) for pain control, which reduces reflex sphincter spasm and enhances healing 2

Most acute fissures heal within 10-14 days with conservative care alone 1

Second-Line Treatment: Topical Pharmacotherapy

If no improvement after 2 weeks of conservative management, add topical calcium channel blockers as the preferred medical therapy. 2

Topical Calcium Channel Blockers (Preferred)

• Diltiazem or nifedipine applied topically for at least 6 weeks 1
• Healing rates: 65-95% with minimal side effects 1, 2
• Pain relief typically occurs after 14 days of treatment 1
• Superior to glyceryl trinitrate due to significantly fewer side effects 2

Alternative: Glyceryl Trinitrate (GTN)

• Healing rates: 25-50%, substantially lower than calcium channel blockers 1
• Common side effect: headache (occurs in up to 77% of patients) 3
• Long-term results are disappointing with recurrence rates of 67% for chronic fissures at 9 months 3
• Should not be first-line topical therapy given inferior efficacy and side effect profile 2

Third-Line Treatment: Botulinum Toxin Injection

If topical treatments fail after 6-8 weeks, consider botulinum toxin injection before proceeding to surgery. 2

• Cure rates: 75-95% with low morbidity 1, 2
• Works by causing temporary sphincter relaxation 2
• More effective than nitroglycerin (96% vs 60% healing) with no adverse effects 4
• Optimal injection location remains controversial 1

Surgical Treatment: Lateral Internal Sphincterotomy

Reserve surgery only for chronic fissures that fail to respond after 8 weeks of non-operative management. 1

• Lateral internal sphincterotomy is the gold standard surgical procedure 1
• Provides faster pain relief and earlier healing compared to medical therapy 5
• Never perform surgery for acute fissures 2
• Avoid manual dilatation due to high risk of temporary and permanent incontinence 1, 2

Critical Evaluation Points

Atypical Fissures Require Further Workup

Evaluate for underlying conditions if fissures are:

• Not located in the posterior midline 1
• Associated with signs of chronicity: sentinel tag, hypertrophied papilla, fibrosis, or visible internal sphincter muscle 1

Consider Crohn's disease, HIV/AIDS, ulcerative colitis, tuberculosis, syphilis, or malignancy 1

Treatment Algorithm Summary

1. Weeks 0-2: Conservative management (fiber, fluids, sitz baths, topical anesthetics) 1, 2
2. Weeks 2-8: Add topical calcium channel blocker if no improvement 2
3. Week 8+: Consider botulinum toxin injection if topical therapy fails 2
4. After failed medical therapy: Lateral internal sphincterotomy for chronic fissures only 1

Common Pitfalls to Avoid

• Do not rush to surgery for acute fissures or before completing 8 weeks of medical management 1, 2
• Do not use manual dilatation due to unacceptable incontinence risk 1, 2
• Do not rely on GTN as first-line topical therapy given inferior healing rates and high headache incidence compared to calcium channel blockers 2
• Do not miss atypical fissures that require evaluation for systemic disease 1