What is the primary treatment for anal fissure in the emergency department?

Emergency Department Treatment of Anal Fissure

For acute anal fissure presenting to the emergency department, initiate non-operative management as first-line treatment with dietary modifications (increased fiber and water intake), topical anesthetics for pain control, and avoid any surgical intervention. 1

Initial Assessment in the ED

• Clinical examination alone is typically sufficient for typical acute anal fissures presenting in the posterior midline 1, 2
• No routine laboratory or imaging studies are needed for typical presentations 1
• For atypical fissures (not midline location), perform focused history and physical examination to rule out inflammatory bowel disease, anal cancer, or occult perianal sepsis 1
• Consider endoscopy, CT, MRI, or endoanal ultrasound only for atypical presentations with suspected underlying pathology 1

Primary ED Treatment Protocol

Conservative Management (First-Line)

Dietary and lifestyle modifications are strongly recommended:

• Increase fiber intake through age-appropriate foods or supplements 1, 2
• Ensure adequate fluid intake to soften stools 1, 2
• Consider stool softeners if dietary changes are insufficient 2
• Recommend warm sitz baths to relax the internal anal sphincter 2, 3

Pain Control Strategy

Pain management is essential as it reduces reflex sphincter spasm and enhances healing 2, 3:

• Apply topical anesthetics (lidocaine) directly to the fissure 1, 2, 3
• Add common oral analgesics (paracetamol) if topical agents provide inadequate relief 1, 4
• Pain relief typically occurs within 14 days of appropriate treatment 2, 4

Antibiotic Considerations

• Topical antibiotics are NOT routinely indicated 1
• Consider topical antibiotics only in cases of poor genital hygiene or reduced therapeutic compliance 1, 2, 4

Critical ED Management Pitfalls

Avoid these interventions in the acute setting:

• Manual dilatation is strongly contraindicated due to high risk of temporary and permanent incontinence 1, 2, 4, 3
• Surgical treatment should not be performed for acute anal fissures 1, 2
• Botulinum toxin injection has no established role in acute fissure management in the ED 1

ED Discharge Instructions and Follow-Up

Expected healing timeline:

• Approximately 50% of acute anal fissures heal within 10-14 days with conservative management 2, 4, 3
• If no improvement after 2 weeks, patients should seek reassessment for additional topical treatments 2, 4

When to consider advanced treatments (outpatient setting):

• Topical calcium channel blockers (diltiazem or nifedipine) for fissures persisting beyond 2 weeks, with healing rates of 65-95% 2, 3
• Glyceryl trinitrate ointment as alternative option with 25-50% healing rates, though headaches are common 2, 3
• Surgical intervention only for chronic fissures non-responsive after 8 weeks of non-operative management 1, 2, 3

Red Flags Requiring Further Evaluation

Instruct patients to return if:

• Fissure location is atypical (lateral rather than midline), suggesting possible Crohn's disease or other pathology 1, 2, 4
• Signs of chronicity develop (sentinel tag, hypertrophied papilla, visible internal sphincter muscle) 2, 4
• No response to conservative treatment after 2 weeks 2, 4
• Systemic symptoms or signs of perianal sepsis develop 1