What are the treatment options for anal fissures?

Treatment of Anal Fissure

Start with conservative management as first-line treatment for all acute anal fissures, combining dietary modifications, stool softeners, and pain control—this approach heals approximately 50% of cases within 10-14 days. 1, 2

Initial Conservative Management (First 2 Weeks)

Dietary and lifestyle modifications form the foundation of treatment:

• Increase fiber intake through diet or supplements to soften stools 1, 2
• Ensure adequate fluid/water intake 1, 2
• Add stool softeners if dietary changes prove insufficient 2
• Warm sitz baths help relax the internal anal sphincter 1, 2

Pain control is essential because it reduces reflex sphincter spasm and promotes healing:

• Apply topical anesthetics (lidocaine 5%) three times daily 3
• Use oral paracetamol or ibuprofen for severe pain 3
• Pain relief typically occurs within 14 days of appropriate treatment 2

Escalation After 2 Weeks of Failed Conservative Treatment

If the fissure persists beyond 2 weeks despite conservative measures, add topical calcium channel blockers as they are more effective than nitroglycerin:

• Diltiazem or nifedipine achieve healing rates of 65-95% 2, 3
• Calcium channel blockers have lower risk of headache and hypotension compared to nitroglycerin 3
• Nitroglycerin ointment has healing rates of only 25-50% with frequent headaches as side effects 2

The evidence strongly favors calcium channel blockers over nitroglycerin—while one older study showed botulinum toxin superior to nitroglycerin 4, and multiple studies demonstrate nitroglycerin's high recurrence rates (67% at 9 months) 5, current guidelines prioritize calcium channel blockers for their superior efficacy and tolerability profile.

Special Considerations for Infected Fissures

When infection or poor genital hygiene is present, combine topical metronidazole cream with lidocaine 5%:

• This combination achieves 86% healing rates versus 56% with lidocaine alone 3
• Apply three times daily for 4 weeks 3
• Provides significantly better pain reduction by week 2 (VAS 2.6 vs 3.3, p=0.004) 3

Surgical Treatment Indications

Reserve surgery for chronic fissures that fail 8 weeks of optimal medical management:

• Lateral internal sphincterotomy remains the gold standard with highest long-term efficacy 6, 7
• Surgery provides faster pain relief (70% at 2 weeks) and healing (85% at 4 weeks) compared to medical therapy 6
• However, surgery carries risk of temporary incontinence (up to 30%) and permanent incontinence (up to 10%) 3

Critical Contraindications

Manual dilatation is absolutely contraindicated due to unacceptably high incontinence risk:

• Temporary incontinence occurs in up to 30% of cases 3
• Permanent incontinence occurs in up to 10% of cases 3
• This technique is no longer recommended by any major guideline 1, 7

Avoid surgery in the acute phase—it should only be considered for chronic fissures unresponsive after 8 weeks of conservative management 2, 3

Red Flags Requiring Further Investigation

Atypical fissures demand evaluation for underlying disease:

• Fissures not located in the posterior midline (or anterior in women) 1, 2
• Multiple fissures 1
• Lateral fissures 1

These atypical presentations require investigation for:

• Inflammatory bowel disease (especially Crohn's disease) 1, 2
• Anorectal cancer 1
• Sexually transmitted diseases (HIV, syphilis, herpes) 1
• Tuberculosis 1

Perform endoscopy, CT scan, MRI, or endoanal ultrasound only when these conditions are suspected 1

Treatment Algorithm Summary

1. Weeks 0-2: Conservative management (fiber, fluids, stool softeners, sitz baths, topical anesthetics)
2. After 2 weeks if no improvement: Add topical calcium channel blockers (diltiazem or nifedipine)
3. After 8 weeks if still unhealed: Consider surgical referral for lateral internal sphincterotomy
4. At any point: If infection present, add topical metronidazole to lidocaine