Fissure treatment
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Anal Fissure Treatment
An anal fissure is a tear in the anoderm of the anal canal, typically at the posterior midline. Management differs between acute (<6 weeks) and chronic (>6 weeks) fissures.
Acute Fissure — Conservative Management
Heals 60–90% of acute fissures (Harrison's, p. 9152):
- Stool softeners (for constipation)
- Increased dietary fiber and fluid intake
- Sitz baths (warm water soaks for 10–15 min, 2–3×/day)
- Topical anesthetics (e.g., lidocaine gel) for pain relief
- Topical glucocorticoids to reduce inflammation
Chronic Fissure — Stepwise Approach
The goal of medical therapy is reduction of internal anal sphincter resting pressure.
| Step | Treatment | Evidence / Notes |
|---|---|---|
| 1st line | Topical calcium channel blocker (e.g., diltiazem 2% or nifedipine ointment 3×/day) | Strong recommendation; healing rate >80% (Management of Benign Anorectal Disorders, p. 9) |
| 2nd line | Botulinum toxin type A (up to 20 units injected into internal sphincter on each side) | Conditional recommendation; used if CCB fails or as alternative (ibid.) |
| 3rd line | Lateral internal sphincterotomy (LIS) | Strong recommendation; surgery of choice for medically refractory fissures |
Surgical Management
Lateral Internal Sphincterotomy (LIS) (Harrison's, p. 9152):
- Approximately one-third of the internal sphincter is divided
- The muscle is typically hypertrophied and easily identified
- High cure rate, but carries a risk of fecal incontinence (flatus or fecal soiling)
- Recurrence rates are higher with medical therapy vs. surgery, but incontinence risk offsets the benefit of early surgery
Anal dilatation is an older surgical option but largely replaced by LIS due to uncontrolled sphincter injury.
Key Principles
- Acute fissures → conservative first; most heal without intervention
- Chronic fissures → topical CCB → botulinum toxin → LIS if refractory
- LIS is highly effective but the risk of incontinence must be discussed with the patient before surgery
- Medical therapy has higher recurrence but preserves continence
Sources: Harrison's Principles of Internal Medicine, 21st Ed., p. 9152; Management of Benign Anorectal Disorders, p. 9
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