What is the best approach for managing a patient with an anal fissure?

Anal Fissure Management

Initial Conservative Management is First-Line for All Acute Fissures

Start with conservative management for all acute anal fissures, as approximately 50% heal within 10-14 days with this approach alone. 1, 2

Conservative Treatment Protocol

• Increase fiber intake to 25-30g daily through age-appropriate foods or supplements to soften stools and minimize anal trauma 3, 1
• Ensure adequate fluid intake to prevent constipation 3, 1
• Add stool softeners if dietary changes prove insufficient 3
• Prescribe warm sitz baths to promote sphincter relaxation 3, 1
• Use topical analgesics (lidocaine 5%) for pain control, as pain reduction helps break the cycle of reflex sphincter spasm 3, 1, 2

Critical Assessment Points

• Examine fissure location carefully - 90% of typical fissures occur in the posterior midline 1
• Atypical locations (off-midline) require urgent evaluation for serious underlying conditions like Crohn's disease or inflammatory bowel disease 3, 1, 2
• Assess for chronicity signs: sentinel tag, hypertrophied papilla, fibrosis, or visible internal sphincter muscle 3, 2

Pharmacologic Therapy for Persistent Fissures After 2 Weeks

If the fissure persists beyond 2 weeks despite conservative management, escalate to topical calcium channel blockers as first-line pharmacologic therapy. 3, 1

Preferred Pharmacologic Options (in order)

1. Compounded 0.3% nifedipine with 1.5% lidocaine applied three times daily achieves 95% healing after 6 weeks by reducing internal anal sphincter tone and increasing local blood flow 1

2. Compounded 2% diltiazem cream applied twice daily for 8 weeks achieves healing rates of 48-75% without the headache side effects of nitroglycerin 1

3. Botulinum toxin injection demonstrates 75-95% cure rates with low morbidity and only transitory mild incontinence 1, 4

4. Topical nitroglycerin (GTN) shows only 25-50% healing rates and causes headaches in many patients, making it a less favorable option 3, 1

Critical Pitfall to Avoid

• Never use hydrocortisone beyond 7 days due to risk of perianal skin thinning and atrophy, which worsens the fissure 1

Surgical Management for Chronic Fissures

Refer for lateral internal sphincterotomy (LIS) after 6-8 weeks of failed medical therapy, as this remains the gold standard with >95% healing rates and 1-3% recurrence rates. 1, 4, 5

Indications for Surgery

• Chronic fissures unresponsive to 6-8 weeks of conservative and pharmacologic management 1, 5
• Acute fissures with severe pain making conservative care intolerable 1
• Recurrent fissures despite optimal medical treatment 5

Surgical Contraindications and Warnings

• LIS is absolutely contraindicated in acute anal fissures - never perform without documented failure of conservative management 1
• Manual anal dilatation is absolutely contraindicated due to unacceptably high permanent incontinence rates of 10-30% 1, 5
• LIS carries a small risk (1-3%) of minor permanent incontinence, though significantly lower than manual dilatation 1
• Wound-related complications (fistula, bleeding, abscess, non-healing wound) occur in up to 3% of patients 1

Special Considerations for Pediatric Patients

• Surgical interventions should be avoided in acute fissures in children 3
• Surgery should only be considered after 8 weeks of failed conservative management in children 3
• Manual dilatation is strongly discouraged in children due to complication risk 3, 2
• Most acute fissures in children heal within 10-14 days with conservative management alone 3, 2

Treatment Algorithm Summary

1. Days 0-14: Conservative management (fiber, fluids, sitz baths, topical analgesics)
2. After 2 weeks if no improvement: Add topical calcium channel blocker (nifedipine/diltiazem) or consider botulinum toxin
3. After 6-8 weeks if still unhealed: Refer for lateral internal sphincterotomy
4. At any point: If off-midline location detected, urgently evaluate for underlying pathology