What is the initial treatment for a rectal fissure?

Initial Treatment for Anal Fissure

Begin with conservative management consisting of fiber supplementation, adequate fluid intake, sitz baths, and topical analgesics—this approach heals approximately 50% of all anal fissures and is the recommended first-line treatment for acute fissures. 1

Diagnostic Confirmation

• Diagnosis is confirmed by visual inspection with gentle traction on the buttocks to efface the anal canal—avoid instrumentation if the patient has severe pain 1
• Most fissures occur in the posterior midline; off-midline location mandates evaluation for Crohn's disease, HIV/AIDS, ulcerative colitis, tuberculosis, syphilis, leukemia, or cancer 1
• Signs of chronicity include sentinel skin tag, hypertrophied anal papilla, fibrosis, and visible internal sphincter muscle at the fissure base 1

Conservative Management Protocol

Dietary and Lifestyle Modifications:

• Increase fiber intake through diet or supplementation to soften stools 1, 2
• Ensure adequate fluid intake to maintain soft stool consistency 1
• Consider stool softeners if dietary changes prove insufficient 2

Local Measures:

• Warm sitz baths to relax the internal anal sphincter 1, 2
• Topical analgesics (such as lidocaine) for pain control 1, 2
• Pain relief typically occurs within 14 days of starting treatment 2, 3

Critical Pitfall: Never perform manual dilatation—this carries a 30% risk of temporary incontinence and 10% risk of permanent incontinence 1, 4

When Conservative Management Fails After 2 Weeks

If the fissure persists beyond 2 weeks despite conservative measures, escalate to topical pharmacologic therapy:

First Choice: Topical Calcium Channel Blockers

• Diltiazem or nifedipine achieve healing rates of 65-95% 2, 4, 5
• Preferred over nitroglycerin due to fewer side effects 4, 5

Second Choice: Glyceryl Trinitrate (GTN)

• 0.2-0.4% nitroglycerin ointment achieves healing rates of 25-50% 1, 2, 4
• Headaches are a common side effect but rarely require cessation 1
• Neither GTN nor calcium channel blocker preparations are commercially available in standardized formulations in the United States 1

Surgical Consideration

Surgery is contraindicated for acute anal fissures 1, 2

• Lateral internal sphincterotomy should only be considered for chronic fissures (>8 weeks) that fail conservative and medical management 1
• This procedure has high cure rates and low relapse rates but carries a risk of minor, sometimes permanent, continence defects 1

Timeline and Follow-Up

• Acute fissures heal within 10-14 days with conservative management in approximately 50% of cases 1, 2, 3
• If no improvement after 2 weeks, add topical pharmacologic therapy 2, 4
• Chronic fissures (>8 weeks) that remain unresponsive warrant surgical referral 1