What are the management options for rectal fissures?

Management of Anal Fissures

For acute anal fissures, start with conservative management including increased dietary fiber, adequate fluid intake, and topical anesthetics for pain control; reserve surgery only for chronic fissures that fail to heal after 8 weeks of non-operative treatment. 1

Initial Assessment

Typical vs. Atypical Fissures

• Most anal fissures occur in the posterior midline and require only clinical examination without laboratory or imaging studies. 1, 2
• Atypical fissures (lateral location, multiple fissures) require focused history, complete physical examination, and consideration of endoscopy, CT, MRI, or endoanal ultrasound to rule out Crohn's disease, inflammatory bowel disease, anal cancer, or occult perianal sepsis. 1, 2
• Signs of chronicity include sentinel tag, hypertrophied papilla, fibrosis, and visible internal sphincter muscle. 3, 4

First-Line Treatment: Conservative Management

Dietary and Lifestyle Modifications

• Increase fiber intake through age-appropriate foods or supplements to soften stools. 1, 3, 2
• Ensure adequate fluid intake to maintain soft stool consistency. 1, 3, 2
• Add stool softeners if dietary changes alone are insufficient. 3
• Warm sitz baths help relax the internal anal sphincter. 3, 2

Pain Management

• Topical anesthetics (lidocaine) applied directly to the fissure provide immediate pain relief. 3, 2
• Add oral analgesics (paracetamol) if topical agents provide inadequate relief. 3, 4, 2
• Pain control is essential because it reduces reflex anal sphincter spasm, which enhances healing. 3, 4
• Pain relief typically occurs within 14 days of starting appropriate treatment. 3, 4, 2

Expected Healing Timeline

• Approximately 50% of acute anal fissures heal within 10-14 days with conservative management alone. 3, 4, 2, 5
• Most acute fissures resolve within a few weeks with conservative care. 6

Second-Line Treatment: Pharmacological Sphincter Relaxation

When to Escalate Treatment

• If the fissure persists beyond 2 weeks despite conservative management, consider topical sphincter relaxants. 3, 4, 2

Topical Calcium Channel Blockers (Preferred)

• Diltiazem or nifedipine ointment has healing rates of 65-95% and should be the preferred pharmacological option. 3, 4, 2, 7
• These agents reduce internal anal sphincter pressure without the side effects associated with nitroglycerin. 7

Glyceryl Trinitrate (Alternative)

• Nitroglycerin ointment has healing rates of 25-50%, lower than calcium channel blockers. 3, 4, 2
• Headaches are a common side effect that limits compliance. 3, 4

Botulinum Toxin Injection

• Botulinum toxin can be considered when topical ointments fail, though evidence for acute fissures is limited. 8, 7
• This option provides temporary sphincter relaxation without permanent alterations in continence. 8

Surgical Management

Indications and Timing

• Surgery should only be considered for chronic fissures that are non-responsive after 8 weeks of non-operative management. 1, 3, 2
• Surgical treatment is strongly discouraged for acute anal fissures. 1, 2

Surgical Approach

• Lateral internal sphincterotomy is the surgical management of choice for chronic and refractory fissures, with the highest healing rates and lowest recurrence. 6, 8, 9, 5
• However, there is a small but significant risk of temporary or permanent fecal incontinence. 8, 9

Critical Management Pitfalls

Contraindicated Interventions

• Manual dilatation is strongly contraindicated due to high risk of temporary and permanent incontinence. 1, 3, 2
• Controlled anal dilatation has insufficient evidence to recommend. 1

Limited Role for Antibiotics

• Topical antibiotics may be considered only in cases of poor genital hygiene or reduced therapeutic compliance. 1, 3, 2
• Routine antibiotic use is not indicated for uncomplicated anal fissures. 1

Follow-Up and Red Flags

When to Reassess

• If no improvement after 2 weeks of conservative management, reassess and consider topical sphincter relaxants. 3, 4, 2
• If no response after 8 weeks of comprehensive non-operative management, consider surgical referral. 1, 3, 2

Warning Signs Requiring Further Evaluation

• Atypical fissure location (not posterior midline) requires evaluation for underlying pathology. 3, 4, 2
• Signs of chronicity warrant more aggressive treatment approaches. 3, 4
• Systemic symptoms or signs of perianal sepsis require prompt evaluation. 2