Anal fissure: Medical and surgical management

Anal fissure: Medical and surgical management

Authors
Elizabeth Breen, MD
Ronald Bleday, MD
Section Editors
Martin Weiser, MD
Lawrence S Friedman, MD
Deputy Editor
Rosemary B Duda, MD, MPH, FACS
Disclosures
All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: Mar 2014. | This topic last updated: Μαϊ 16, 2012.

INTRODUCTION — An anal fissure is one of the most common benign anorectal

conditions that may result from high anal pressure. Anal fissures may be acute or
chronic. Acute fissures may result from local trauma or may be secondary to an
underlying medical/surgical condition.

DEFINITION — An anal fissure is a tear in the anoderm distal to the dentate line
(figure 1) [1]. By definition, an acute anal fissure typically heals within six weeks
with conservative local management, while a chronic anal fissure fails conservative
management and requires a more aggressive, surgical approach [1-4]. The etiology of
the fissure determines if it is primary (eg, local trauma) or secondary (eg,
inflammatory bowel disease, malignancy).

PATHOGENESIS — An anal fissure is the result of the stretching of the anal mucosa
beyond its normal capacity. Once the tear occurs, it begins a cycle leading to repeated
injury. The exposed internal sphincter muscle beneath the tear goes into spasm. In
addition to causing severe pain, the spasm pulls the edges of the fissure apart, which
impairs healing of the wound. The spasm also leads to further tearing of the mucosa
with the passage of subsequent bowel movements. This cycle leads to the
development of a chronic anal fissure in approximately 40 percent of patients [2].

It has been proposed that ischemia may contribute to the development of an anal
fissure. Blood flow in the anoderm at the posterior midline, the site of most fissures, is
less than one-half that in other quadrants in the anal canal [5,6]. Furthermore, the rate
of perfusion is inversely related to anal pressure and, in one study, patients with
chronic anal fissure had higher anal pressures than those with fecal incontinence,
hemorrhoids, or other colorectal disorders, or controls [5]. The demonstration of
reduced blood flow provided the rationale for the use of topical nitroglycerin in the
treatment of this disorder (see "Anal fissure: Medical and surgical management",
section on 'Topical nitroglycerin').

The elevation in anal pressure in patients with chronic anal fissure may result from
increased tone of the internal anal sphincter, which can be demonstrated
manometrically [7-9]. In one study, for example, manometry was performed in 12
patients with chronic anal fissure and in 12 controls [7]. The mean average resting
pressure of the internal sphincter was significantly higher in patients with a chronic
anal fissure (120 versus 83 mmHg).

The most common location for a primary anal fissure is the posterior anal midline;
only 10 percent of females and 1 percent of males have a primary anal fissure located
in the anterior midline [2]. Patients with an anterior fissure are more likely to have
occult external sphincter injury and impaired external sphincter function compared
with patients with a posterior fissure [1]. Factors other than reduced blood flow also
may contribute to the posterior predilection for anal fissures. Elevated internal
sphincter pressures are not confined to the site of the fissure; in one study, they were
highest on the distal anterior surface, which may favor posterior mucosal tearing
during defecation [7]. Another hypothesis is the elliptical arrangement of anal
sphincter fibers, which lends less support to the posterior aspect of the anal canal.

EPIDEMIOLOGY — Anal fissures most often affect infants and middle-age

individuals. The true prevalence of anal fissures in adults is unknown, as anorectal
discomfort is often attributed to symptomatic hemorrhoids [10]. It is estimated that
approximately 235,000 new cases of anal fissure occur every year in the United States
[2].

ETIOLOGY — The majority of anal fissures are primary and caused by local trauma,
such as passage of hard stool, prolonged diarrhea, vaginal delivery, or anal sex.
Secondary anal fissures can be found in patients with previous anal surgical
procedures; inflammatory bowel disease (eg, Crohn's disease); granulomatous
diseases (eg, extrapulmonary tuberculosis, sarcoidosis); malignancy (eg, squamous
cell anal cancer, leukemia); and communicable diseases (eg, HIV infection, syphilis,
chlamydia) [2,11]. These conditions are discussed as separate topics.

CLINICAL MANIFESTATIONS

Patient presentation — Patients with an acute anal fissure present with tearing pain
accompanying the passage of bowel movements. Patients may also describe bright
rectal bleeding, usually limited to a small amount on the toilet paper or on the surface
of stool. Some patients complain of perianal pruritus and/or skin irritation. Patients
with a chronic fissure typically have less intense pain.

Physical examination — The most common location for a primary anal fissure is the
posterior anal midline [2]. The fissure is typically identified as a laceration ranging in
depth from a superficial, shallow laceration to a deep wound extending into the
external sphincter [12].

An acute fissure appears as a fresh laceration, much like a paper cut; a chronic fissure
has raised edges exposing the white, horizontally oriented fibers of the internal anal
sphincter muscle fibers at the base of the fissure (picture 1).

Chronic anal fissures are often accompanied by external skin tags (sentinel pile) at the
distal end of the fissure, and hypertrophied anal papillae at the proximal end. The
features of a chronic fissure are attributed to chronic infection and the development of
fibrotic connective tissue [2].
DIAGNOSIS — The diagnosis of anal fissure is based on the history of painful
defecation and the physical examination finding of a superficial tear in the anoderm. A
primary fissure typically occurs posteriorly; secondary fissures occur laterally as well
as posteriorly [2,3]. The pathognomonic feature of an acute fissure is a superficial
tear, while a chronic fissure appears hypertrophied with skin tags and/or papillae.

DIAGNOSTIC EVALUATION — The best approach to diagnose an anal fissure

during physical examination is to spread the buttocks apart gently, looking carefully
in the posterior midline. Patients are often too uncomfortable to tolerate a digital
rectal examination or anoscopy. The second most frequent location is the anterior
midline, which should also be inspected [12]. Eccentrically located (lateral) fissures
occur, but are most often associated with atypical etiologies (eg, inflammatory bowel
disease, granulomatous diseases).

DIFFERENTIAL DIAGNOSIS

Perianal ulcers or sores — Anal ulcers can be caused by inflammatory bowel diseases
and granulomatous diseases (eg, Crohn’s, tuberculosis [13,14]), and sexually
transmitted diseases (eg, syphilis [15]). A primary fissure, while technically an ulcer,
is thinner than ulcers caused by underlying conditions (See "Perianal complications of
Crohn disease" and "Cutaneous manifestations of tuberculosis", section on 'Metastatic
tuberculous abscesses (tuberculous gummas)'.)

Anorectal fistula — An anorectal fistula typically presents as a painful, purulent

draining perirectal skin lesion. If probed, a track can be identified extending from the
perianal skin to the anus or rectum. A fissure does not have a track. (See "Anorectal
fistula: Clinical manifestations, diagnosis, and management principles".)

Solitary rectal ulcer syndrome — Solitary rectal ulcer syndrome is an uncommon

rectal disorder that can present with bleeding, passage of mucus, straining during
defecation, and a sense of incomplete evacuation. The name of the syndrome is
misleading, since patients can often present with lesions that are neither solitary nor
ulcerated. Findings vary and can include mucosal ulcerations, polypoid and mass
lesions (mimicking rectal cancer) or simply erythema. The lesions are located in the
anterior rectal wall within 10 cm of the anal verge in the majority of patients.
Symptoms are variable (eg, rectal bleeding, pelvic fullness, straining, tenesmus, pain)
or may be absent. (See "Solitary rectal ulcer syndrome".)

POSTDIAGNOSTIC EVALUATION — Patients with rectal bleeding should undergo

endoscopy. A sigmoidoscopy may be reasonable in patients younger than 50 who have
no family history of colon cancer; in other patients, a full colonoscopy should be
performed. Patients who have atypical fissures (eg, lateral, anterior) or other clinical
features raising suspicion for underlying Crohn's disease should have a full
colonoscopy and imaging of the small bowel. (See "Clinical manifestations, diagnosis
and prognosis of Crohn disease in adults", section on 'Small bowel disease'.)

PREVENTION — Anal fissures can be prevented by using proper anal hygiene,

including keeping the anal area dry, and wiping with a soft cotton or moistened cloth
[4,11]. Other measures that may be helpful include preventing constipation by
consuming a high fiber diet and adequate fluids, avoiding straining during defecation,
avoiding trauma to the anus, and prompt treatment of diarrhea. (See "Management of
chronic constipation in adults" and "Prevention and treatment of acute constipation in
infants and children" and "Constipation in the older adult".)

TREATMENT

Medical therapy — Medical therapy has traditionally consisted of three components:

relaxation of the internal sphincter, institution and maintenance of atraumatic passage
of stool, and pain relief. In many cases, these goals can be accomplished with fiber
therapy to keep the stools soft and formed, and warm sitz baths following bowel
movements to relax the sphincter [4]. Topical anesthetic creams to soothe the
inflamed anoderm are often prescribed, but have not been shown to be more effective
than fiber and sitz baths alone [5]. (See "Management of chronic constipation in
adults", section on 'Dietary changes and bulk forming laxatives'.)

Topical and injection therapies

Topical nitroglycerin — The observation that the posterior commissure of the internal
anal sphincter is less perfused than the other sections led to the concept that ischemia
could be contributing to the persistence of anal fissures [6,7]. Topical nitroglycerin
increases local blood flow and reduces pressure in the internal anal sphincter, which
may further facilitate healing. It is applied as a 0.2 to 0.4 percent ointment and is
typically given for eight weeks. In 2011, the US Food and Drug Administration
approved a 0.4 percent nitroglycerin ointment (Rectiv, ProStrakan Group). Prior to
that, the commercially available nitroglycerin ointments in the United States were 2
percent, a concentration that may not be well tolerated [8]. A 0.2 percent
concentration can be custom-made by a pharmacist.

Topical nitroglycerin has been evaluated in multiple series and in controlled trials that
have generally shown a beneficial effect compared with placebo, although discordant
data have been reported [9-16]. A meta-analysis of 75 randomized trials of medical
therapy for anal fissures found that topical nitroglycerine was better than placebo in
the healing of anal fissures (49 verus 36 percent), but that fissures recurred in 50
percent of patients [17].

The major side effect of topical nitroglycerine is headache. In one study, it occurred
10 to 15 minutes after application and lasted no more than 30 minutes in most patients
[18]. Headaches occurred most commonly after two weeks of therapy, and decreased
thereafter. As with other forms of nitrate therapy, patients taking sildenafil (Viagra)
are at increased risk for hypotension. Nitrates should not be prescribed within 24
hours of taking this medication (see "Treatment of male sexual dysfunction" and
"Patient information: Anal fissure (Beyond the Basics)").

Topical diltiazem — A pilot study included 15 patients treated with topical diltiazem
gel (2 percent; not commercially available in the United States) applied three times
daily for eight weeks [19]. Healing was achieved in 10 of 15 patients (67 percent)
without headache or other significant side effects.

Similar results with topical diltiazem were observed in a separate study of 71 patients;
healing was observed in 75 percent after two to three months of treatment [20].
Twenty-seven of the 41 responding patients (66 percent) remained symptom free
during a median of 32 weeks of follow-up. Six of seven patients with recurrent
symptoms were successfully treated with a second course. No side effects were
reported. In another report, topical diltiazem was associated with healing in 19 of 39
patients who had failed to heal with topical nitroglycerin [21].

Topical bethanechol — The pilot study of diltiazem also included 15 patients treated
with topical bethanechol gel (0.1 percent; also not commercially available in the
United States) applied three times daily for eight weeks [19]. Topical bethanechol was
effective in healing anal fissures in 9 of 15 patients (60 percent), again without
headache or other significant side effects.

Botulinum toxin — Botulinum toxin is a potent inhibitor of the release of

acetylcholine from nerve endings and has been used successfully for decades to treat
certain spastic disorders of skeletal muscle such as blepharospasm and torticollis, and
more recently, for achalasia. Injection of botulinum toxin into the anal sphincter can
improve healing in patients with chronic anal fissure. It is typically given as injections
around the anal canal (10 to 100 units total).

In one study, 30 consecutive patients with chronic anal fissure were randomized to
intrasphincteric botulinum toxin type A or saline injection [22]. Injection was
accomplished by palpation of the internal anal sphincter and administration of a total
volume of 0.4 mL (in two equal doses for a total of 20 units of botulinum toxin) via a
27-gauge needle close to the fissure on each side. No sedation or local anesthesia was
used. After two months, significantly more patients who had received botulinum toxin
had healed (73 versus 13 percent). Four patients who had received botulinum toxin
required a second injection (25 units), and all subsequently healed. No relapses
occurred during an average follow-up of 16 months. One patient developed temporary
flatus incontinence. Temporary fecal incontinence after therapy has been reported in
other series [23,24].

As suggested in the above study [22], repeated therapy with botulinum toxin may be
beneficial for patients who relapse or do not respond to initial treatment. This was
underscored in a series that included 50 patients, 20 of whom had relapsed following
initial treatment, and 30 of whom had failed initial treatment [24]. The 20 patients
who relapsed were retreated with the same dose as initial treatment (5 units), while
the 30 in whom treatment had failed were retreated with a higher dose (10 units).
Nineteen of the 20 patients (95 percent) treated with 5 units were pain-free within one
week, and healing was observed in 70 percent by three months. In the group treated
with 10 units, 22 of 30 (73 percent) became pain-free by one week, and 19 (63
percent) showed healing three months after injection. Transient mild incontinence was
observed in two patients (7 percent). Initial treatment failures may have been due to a
relatively low dose of botulinum toxin compared with other reports [22]. However,
pathologic causes of recurrent or unhealing fissures (such as inflammatory bowel
disease) should be considered in these patients.

The long-term outcome of patients treated with botulinum toxin has not been well
described, but recurrence appears to be common. One report with the longest follow-
up included 57 patients who had completely healed six months after injection and
were followed for 42 months [25]. A recurrent fissure was observed in 22 patients (42
percent). Compared with patients who achieved long-term healing, those with
recurrence were significantly more likely to have had anterior fissures (45 versus 6
percent), had a longer duration of disease, needed reinjection (59 versus 26 percent),
required a higher total dose to achieve healing, and had not achieved as great a
percentage decrease of maximum anal squeeze pressure after injection.

Topical nitroglycerin plus botulinum toxin — A possible additive effect of topical

nitroglycerin plus botulinum toxin injection was evaluated in a controlled trial
involving 30 patients who did not respond to topical nitroglycerin [26]. Patients were
randomly assigned to botulinum toxin injection with or without topical nitroglycerin.
The healing rate at six weeks was significantly higher in those who received
combination therapy (66 versus 20 percent). No significant differences were seen at 8
and 12 weeks.

Oral therapies

Oral nifedipine — The ability of the calcium channel blocker nifedipine to reduce
resting internal anal sphincter pressure prompted its use for the treatment of patients
with chronic anal fissures. In an open label trial, 15 patients were treated with a slow-
release nifedipine (Adalat, Bayer pharmaceuticals, 20 mg twice daily) for eight weeks
[27]. Treatment was associated with an initial reduction in maximum anal resting
pressure and pain scores. Complete healing was observed in nine patients (60 percent)
after eight weeks, while three additional patients were asymptomatic. Ten patients
experienced flushing, one developed mild ankle edema, and four had mild headaches.
This study has been criticized because of the short duration of follow-up, frequent
side effects, relatively poor efficacy of nifedipine compared with other approaches,
and lack of a control group [28].

Oral diltiazem — The efficacy of topical versus oral diltiazem was evaluated in a
controlled trial involving 50 patients [29]. Complete fissure healing by eight weeks
was observed in nine patients (38 percent) receiving oral diltiazem compared with 15
patients (65 percent) receiving topical treatment. Side effects were more common in
those receiving oral therapy.

Comparisons of therapies

Topical nifedipine versus topical nitroglycerin — The efficacy of topical nifedipine

was compared with topical nitroglycerin in a randomized controlled trial involving 52
patients [30]. The healing rate was higher with nifedipine (89 versus 58 percent) and
treatment side effects were less frequent (5 versus 40 percent). Reductions in pain
scores were significantly lower in both groups. Recurrence developed in a similar
proportion of patients (42 and 31 percent, respectively) after a mean of 183 and 124
weeks, respectively.

Topical nitroglycerin versus botulinum toxin — At least three randomized controlled

trials have compared topical nitroglycerin with botulinum toxin A [31-33]. Two of
them were performed by the same group [31,33]:
  The largest trial (involving 100 patients) found significantly higher rates of
healing at two months in patients randomized to botulinum toxin A (92 versus
70 percent) [33].
 A similarly higher rate of healing with botulinum toxin A at two months (96
versus 60 percent) was observed in a second trial involving 50 patients [31].

Side effects (mainly headache) were more frequent in the nitroglycerin group.
However, mild (mainly transient) incontinence to flatus was observed more frequently
in the botulinum toxin group. Patients with side effects (or an incomplete response) to
one treatment often had success when crossed to the other.

A meta-analysis also found that topical nitroglycerin and botulinum toxin had similar
healing rates [17]. A reasonable conclusion is that both treatments are acceptable
options for first-line therapy; one or the other option can be used in patients who do
not respond, or who are intolerant to treatment. Botulinum toxin appears to be
somewhat more effective (at least with short-term follow-up) but has a higher
frequency of mild incontinence. Because botulinum toxin is more invasive and is
associated with a greater risk of mild incontinence, we generally reserve it for patients
who have not responded to topical nitroglycerin (see "Anal fissure: Clinical
manifestations, diagnosis, prevention").

Topical diltiazem versus botulinum toxin — Topical diltiazem and botulinum toxin
appear to be similarly effective. Short-term healing rates were better for patients
treated with botulinum toxin injections compared with topical diltiazem, but healing
rates at three months and pain reduction were found to be equivalent. In a randomized
trial including 143 patients with anal fissures treated with botulinum toxin and a
placebo cream or topical diltiazem and a placebo (saline) injection, there was no
significant difference in healing (43 percent for both groups) or pain reduction (82
versus 78 percent) at three months follow-up [34].

Surgical therapy — Surgery should be reserved for patients in whom anal fissures fail
to heal despite adequate medical therapy. The goal of surgical therapy is to relax the
internal anal sphincter, which is most often accomplished by a lateral internal
sphincterotomy. This procedure involves division of the internal anal sphincter from
its distal-most end for a distance equal to that of the fissure, or up to the dentate line.
The sphincter can be divided in a closed or open fashion, depending upon the
preference of the surgeon. The sphincterotomy heals best if it is performed in the right
or left lateral position, and not in the posterior or anterior midline. The fissure itself
does not require surgical therapy (eg, fissurectomy) unless it has an atypical
appearance and a biopsy is warranted.

Lateral sphincterotomy is successful in approximately 95 percent of patients [35-37]

and has a significantly higher healing rate than medical therapy [17]. In one series of
350 patients who underwent open or closed lateral internal anal sphincterotomy for
acute or chronic anal fissure, only 21 patients (6 percent), failed to heal or developed
a recurrence [36]. Five of these patients were eventually diagnosed with Crohn's
disease. Postoperative infections developed in eight patients (2 percent), four of which
were associated with fistulas. Incontinence for flatus or stool, which was usually
transient, developed in 17 percent. The results were similar for the open and closed
methods.
Lateral sphincterotomy versus topical nitroglycerin — At least two controlled trials
have compared the efficacy of lateral sphincterotomy versus topical nitroglycerin
therapy [38,39]. One trial involved 65 patients who were randomly assigned to one or
the other modality [38]. Healing at eight weeks was observed significantly more often
in those randomized to surgery (97 versus 61 percent). Twelve patients who received
topical nitroglycerin eventually underwent lateral sphincterotomy. Poor tolerance and
compliance were risk factors for failure to heal with topical nitroglycerin.

A second study included 54 patients who were followed for up to two years after
treatment [39]. In the nitroglycerin group, 18 patients (67 percent) healed by five
weeks and 24 (89 percent) by ten weeks. Minor side effects were experienced by eight
patients (30 percent). In the surgical group, 26 (96 percent) healed by five weeks and
100 percent by ten weeks. Minor fecal incontinence was experienced by 44 percent,
which remained in 15 percent after 24 months follow-up. The percentage of patients
healed at the five-week point was significantly higher in the surgical group. The
author concluded that nitroglycerin should be considered as the first choice with
surgery reserved for patients in whom treatment is unsuccessful.

Lateral sphincterotomy versus botulinum toxin injection — At least one controlled

trial has directly compared lateral sphincterotomy with botulinum toxin injection [40].
The authors concluded that the proportion of patients with healing after botulinum
toxin A injection was high overall (albeit lower than sphincterotomy at one year), but
the rate of healing was slower than with lateral sphincterotomy. However, botulinum
toxin injection was associated with fewer complications and faster recovery.

The study included 111 patients with chronic anal fissures who were randomly
assigned to treatment with botulinum toxin or to lateral sphincterotomy [40]. Patients
were assessed at regular intervals for one year. Complete healing was observed in 64
percent of patients in the botulinum group at two months. Ten nonresponding patients
underwent a second injection yielding an overall healing rate of 87 percent at six
months. The healing rate was significantly higher by two months in the
sphincterotomy group (98 versus 64 percent), but was similar to the botulinum group
at six months (96 versus 87 percent). After one year, there were seven recurrences in
the botulinum group resulting in an overall success rate of 75 percent; there were no
recurrences after six months in the sphincterotomy group (two patients had
recurrences prior to six months). Complication rates were significantly higher in the
sphincterotomy group (including eight cases of fecal incontinence versus none in the
botulinum group). Full return to normal activities was also more rapid in the
botulinum group.

Lateral sphincterotomy versus oral nifedipine — A controlled trial randomly assigned

132 patients with a chronic anal fissure to a lateral sphincterotomy, a tailored
sphincterotomy, or oral nifedipine [41]. The surgical approaches were associated with
significantly better fissure healing rates at 16 weeks and less recurrence. Compliance
with nifedipine was poor due to side effects and slow healing. There was no
difference in continence between the three treatment groups.

Risk of incontinence — As noted above, a concern with surgery for anal fissures is
the risk of fecal incontinence. Fecal incontinence can be characterized as either minor
(defined as inadvertent escape of flatus or partial soiling of undergarments with liquid
stool) or major (involuntary excretion of feces). (See "Fecal incontinence in adults".)
Most series of sphincterotomy for anal fissures have described only minor
incontinence. The risk has varied among reports from as low as 0 to as high as 24
percent [42]. In most reports the risk has been less than 10 percent.

However, it is possible that the rates reported in many studies may be underestimates,
a point that was illustrated in a survey study involving 298 patients who underwent
sphincterotomy [43]. Significantly more patients reported minor incontinence than
was recorded in the medical record. Temporary incontinence was reported by 31
percent of patients while 30 percent described persistent incontinence to gas. No
patients described major incontinence. Fecal incontinence was more likely in women
who had two or more previous vaginal deliveries.

Another survey study included 487 patients who had undergone lateral internal
sphincterotomy [37]. Fissures had healed by a median of three weeks after surgery in
96 percent of patients and were recurrent in only 8 percent. Some degree of fecal
incontinence was reported in 45 percent of patients at some time in the postoperative
period and was more likely in women (53 versus 33 percent). Incontinence to flatus,
mild soiling, and gross incontinence occurred in 31, 39, and 23 percent of patients
respectively. However, by the time of the survey (an average of five years after the
procedure), only six percent reported incontinence to flatus, while eight percent had
minor fecal soiling, and one percent experienced loss of solid stool. Only three
percent of patients reported that incontinence had ever affected their quality of life.

Considered together, these data suggest that 30 to 45 percent of patients will

experience minor incontinence following lateral sphincterotomy, which persists in 6
to 30 percent of patients after long-term follow-up. This can be compared to a
background rate of fecal incontinence in the general population of approximately 2
percent [44]. The risk is increased in women, particularly those who have had
previous vaginal deliveries. The minor incontinence generally does not have a major
impact on quality of life. Major incontinence is rare.

Dilation — A Lord's or four finger dilatation in the operating room has been used for
the treatment of anal fissures [45]. Although this treatment can improve the spasm in
the internal anal sphincter, it is associated with a high incidence of sphincter tears and
fecal incontinence.

Pneumatic balloon dilation has also been performed for treatment of chronic anal
fissures [46]. Experience is limited and it has not been compared directly with other
approaches.

Recommendation — An optimal strategy for the management of anal fissures has not
been established. Our current approach based upon the published literature and
clinical experience is illustrated in the following algorithm (algorithm 1).

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education

materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces
are written in plain language, at the 5th to 6th grade reading level, and they answer the
four or five key questions a patient might have about a given condition. These articles
are best for patients who want a general overview and who prefer short, easy-to-read
materials. Beyond the Basics patient education pieces are longer, more sophisticated,
and more detailed. These articles are written at the 10th to 12th grade reading level and
are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage
you to print or e-mail these topics to your patients. (You can also locate patient
education articles on a variety of subjects by searching on "patient info" and the
keyword(s) of interest.)

 Basics topics (see "Patient information: Anal fissure (The Basics)")

 Beyond the Basics topics (see "Patient information: Anal fissure (Beyond the
Basics)")

SUMMARY AND RECOMMENDATIONS

 The goals of therapy are to break the cycle of sphincter spasm and tearing of
the anal mucosa, and to promote healing of the fissure. An optimal strategy for
the management of anal fissures has not been established. Our current
approach based upon the published literature and clinical experience is
illustrated in the following algorithm (algorithm 1). (See 'Introduction' above.)
 Medical therapy is successful in many patients, with surgery being reserved
for refractory cases. In many cases, these goals can be accomplished with fiber
therapy to keep the stools soft and formed, and warm sitz baths following
bowel movements to relax the sphincter. Options for patients who fail to
respond to these measures include topical nitroglycerin and botulinum toxin
injection. (See 'Medical therapy' above.)
 Topical nitroglycerin increases local blood flow and reduces pressure in the
internal anal sphincter, which may further facilitate healing. It is applied as a
0.2 to 0.4 percent ointment. Trials have generally shown a beneficial effect of
nitroglycerin compared with placebo. The most common side effect is
headache. (See 'Topical nitroglycerin' above.)
 Botulinum toxin is a potent inhibitor of the release of acetylcholine from nerve
endings. Injection of botulinum toxin into the anal sphincter can improve
healing in patients with chronic anal fissure and repeated therapy with
botulinum toxin may be beneficial for patients who relapse or do not respond
to initial treatment. The long-term outcome of patients treated with botulinum
toxin has not been well described, but recurrence appears to be common. (See
'Botulinum toxin' above.)
 Studies suggest that either topical nitroglycerin or botulinum toxin injection is
a reasonable treatment for patients who require therapy beyond fiber and sitz
baths. In addition, patients can be switched to the other treatment if they do
not respond or are intolerant to the initial treatment. Botulinum toxin appears
to be somewhat more effective (at least with short-term follow-up) but has a
higher frequency of mild incontinence. Because botulinum toxin is more
invasive and is associated with a greater risk of mild incontinence, we
generally reserve it for patients who have not responded to topical
nitroglycerin. (See 'Topical nitroglycerin versus botulinum toxin' above.)
 Surgery should be reserved for patients in whom anal fissures fail to heal
despite adequate medical therapy. The goal of surgical therapy is to relax the
 internal anal sphincter, which is most often accomplished by a lateral internal
sphincterotomy. Lateral sphincterotomy is successful in approximately 95
percent of patients. However, 30 to 45 percent of patients will experience
minor incontinence following lateral sphincterotomy, which persists in 6 to 30
percent of patients after long-term follow-up. The risk is increased in women,
particularly those who have had previous vaginal deliveries. The minor
incontinence generally does not have a major impact on quality of life, and
major incontinence is rare. (See 'Surgical therapy' above.)

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