Treatment for Anal Fissures
First-Line Treatment: Conservative Management
Start all patients with acute anal fissures on conservative management, which heals approximately 50% of cases within 10-14 days. 1, 2
The initial approach should include:
- Increase dietary fiber through age-appropriate foods or supplements to soften stools 3, 1
- Ensure adequate fluid intake to maintain soft stool consistency 3, 1, 2
- Prescribe stool softeners if dietary modifications prove insufficient 3
- Recommend warm sitz baths to relax the internal anal sphincter 3, 1
- Provide topical anesthetics (lidocaine) applied directly to the fissure for immediate pain relief 4, 3, 2
- Add oral analgesics (paracetamol or ibuprofen) if topical agents provide inadequate relief 4, 2
Pain relief typically occurs within 14 days of starting appropriate treatment. 4, 3, 2
Second-Line Treatment: Pharmacological Sphincter Relaxation
If the fissure persists beyond 2 weeks despite conservative management, prescribe topical calcium channel blockers (diltiazem or nifedipine) for at least 6 weeks. 4, 3, 1, 2
Calcium channel blockers are superior to other medical options:
- CCBs achieve healing rates of 65-95%, significantly better than glyceryl trinitrate 4, 3, 1, 2
- CCBs cause fewer side effects than nitroglycerin, particularly avoiding the severe headaches and hypotension associated with GTN 4
- Topical application is preferred over systemic administration due to similar efficacy with fewer systemic side effects 4
- Treatment duration should be at least 6 weeks, with pain relief typically occurring after 14 days 4, 3
Alternative pharmacological options if CCBs are unavailable:
- Glyceryl trinitrate (GTN) 0.2% achieves healing rates of 25-50% but causes headaches in up to 77% of patients 1, 2, 5, 6
- Botulinum toxin injection achieves cure rates of 75-95% with low morbidity, though it requires specialized expertise and the optimal injection location remains controversial 1, 7
Surgical Treatment: Reserved for Chronic Fissures
Surgery should only be considered for chronic fissures that fail to respond after 8 weeks of non-operative management, or for acute fissures with severe disabling pain. 1, 2
- Lateral internal sphincterotomy (LIS) is the gold standard surgical procedure for chronic anal fissures 1, 8
- LIS carries wound-related complications including fistula, bleeding, abscess, or non-healing wound in up to 3% of patients 4
- Manual dilatation is absolutely contraindicated due to temporary incontinence rates reaching 30% and permanent incontinence rates up to 10% 4, 2
Critical Pitfalls to Avoid
Never perform manual dilatation - this outdated practice causes unacceptably high rates of both temporary and permanent fecal incontinence. 4, 2
Do not rush to surgery for acute fissures - surgical intervention should be avoided in acute presentations except for severe disabling pain. 1, 2
Recognize atypical fissures requiring further workup:
- Lateral location (not posterior midline) requires evaluation for Crohn's disease, ulcerative colitis, HIV/AIDS, tuberculosis, syphilis, or malignancy 3, 1, 2
- Signs of chronicity include sentinel tag, hypertrophied papilla, fibrosis, and visible internal sphincter muscle 3, 1, 2
Special Considerations for Pediatric Patients
In children, surgical interventions should be avoided even more stringently - lateral internal sphincterotomy should only be considered for chronic fissures non-responsive after 8 weeks of conservative management. 3
Topical antibiotics (metronidazole cream) may be considered in cases of poor genital hygiene or reduced therapeutic compliance, though this is based on weak evidence. 4, 3
Follow-Up Protocol
Reassess patients at 2 weeks - if no improvement, escalate to topical calcium channel blockers. 3, 2
Reassess again at 8 weeks - if still no response, consider referral for surgical evaluation or botulinum toxin injection. 3, 1, 2
The high recurrence rate with nitroglycerin (67% for chronic fissures at 9 months) makes it a less desirable option compared to calcium channel blockers. 6