Treatment of Anal Fissures
Start with dietary modifications (increased fiber and water intake) combined with warm sitz baths for all acute anal fissures, and add topical calcium channel blockers (0.3% nifedipine with 1.5% lidocaine three times daily) if conservative measures alone don't provide relief within 2 weeks. 1
First-Line Conservative Management
All patients with acute anal fissures should receive non-operative management as the initial treatment approach. 2, 1
Dietary and Lifestyle Modifications
- Increase fiber intake through diet or supplements to soften stools, which heals approximately 50% of acute fissures within 10-14 days 2, 1, 3
- Ensure adequate water consumption to prevent constipation and promote healing 2, 1
- Recommend warm sitz baths to promote sphincter muscle relaxation 2, 1
Pain Management
- Apply topical anesthetics (lidocaine) directly to the fissure for immediate pain control 1, 3
- Add oral analgesics (paracetamol) if topical agents provide inadequate relief 3
- Pain relief typically occurs within 14 days of appropriate treatment 1, 3
Pharmacological Treatment for Persistent Fissures
If no improvement occurs after 2 weeks of conservative measures, escalate to topical calcium channel blockers. 1, 3
Preferred Topical Agent
- Apply 0.3% nifedipine with 1.5% lidocaine three times daily for at least 6 weeks, which achieves 95% healing rates 1
- Calcium channel blockers work by blocking calcium channels in vascular smooth muscle, reducing internal anal sphincter tone and increasing blood flow to the ischemic ulcer 1
- Calcium channel blockers are preferred over glyceryl trinitrate (GTN) because they offer similar healing rates (65-95% vs 25-50%) with fewer side effects and better patient compliance 1, 3, 4
Alternative Topical Options
- Glyceryl trinitrate ointment can be considered as an alternative, though headaches are common and healing rates are lower 3
- Botulinum toxin injection is nearly as effective as surgery for chronic fissures but has no established role in acute fissure management 3, 5
Surgical Intervention
Reserve surgery exclusively for fissures that fail to respond after 8 weeks of comprehensive non-operative management. 1, 3
Surgical Approach
- Lateral internal sphincterotomy is the gold standard surgical procedure, achieving healing in more than 95% of cases with recurrence rates of only 1-3% 1, 5
- Surgery should never be performed for acute fissures 1, 3
Critical Pitfalls to Avoid
Absolutely Contraindicated Procedures
- Never perform manual dilatation due to the high risk of temporary and permanent fecal incontinence 2, 1, 3
- Never rush to surgery for acute fissures—always attempt non-operative management first 1, 3
Red Flags Requiring Further Evaluation
- Atypical fissure location (lateral rather than posterior midline) suggests possible Crohn's disease, inflammatory bowel disease, or malignancy 1, 3
- Multiple fissures warrant investigation for underlying pathology 2
- Failure to heal after appropriate treatment requires evaluation for inflammatory bowel disease, anal cancer, or occult perianal sepsis 2, 3
- For atypical presentations, perform focused history and physical examination, and consider endoscopy, CT, MRI, or endoanal ultrasound only when suspecting underlying pathology 2, 3
Treatment Timeline and Expectations
Acute Phase (0-2 weeks)
- Initiate dietary modifications, sitz baths, and topical anesthetics immediately 1, 3
- Reassess at 2 weeks to evaluate pain relief and healing progress 1, 3
Subacute Phase (2-8 weeks)
- Add topical calcium channel blockers if no improvement after 2 weeks 1, 3
- Continue treatment for minimum 6 weeks 1
- Pain relief typically occurs after 14 days of calcium channel blocker therapy 1