management

Last reviewed 01/2018

Conservative management:

• initial approach in the treatment of anal fissures is non-operative. An acute anal fissure may heal spontaneously or in response to medical therapy with warm baths, stool softeners, bulk laxatives, analgesics, topical anaesthetics and re-assurance
• introduction of more bran into the diet together with laxatives and analgesic suppositories
• some suggest the use of a plastic anal dilator - however others state that regular anal dilatation to treat anal fissures is not recommended (1)
• topical glyceryl trinitrate may be beneficial
• topical formulation of diltiazem (Topical 2% diltiazem)
  • valid alternative to GTN
  • data to suggest that topical diltiazem heals GTN-resistant fissures (2)
• botulinum toxin injections may be used as an alternative to treatment with GTN (or in patients in whom GTN fails)
• a review suggest that topical GTN or diltiazem would be suitable as first-line therapy with botulinum toxin used as rescue treatment (2)

Surgical management - this can bring immediate relief:

• internal sphincterotomy:
• in studies with short term follow-up the healing rate was 92-100%
• manual dilatation:
• reduces sphincter pressure
• results in healing in 40-70%
• results in incontinence in 25-75%
• is rarely indicated

Reference:

• 1) McDonald P, Driscoll AM, Nicholls RJ. The anal dilator in the conservative management of acute anal fissures. Br J Surg. 1983;70:25–6
• 2) Bhardwaj R, Parker MC.Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl. 2007 Jul;89(5):472-8.