Anal fissure: Medical management
- Ronald Bleday, MD
Ronald Bleday, MD
- Associate Professor of Surgery
- Harvard Medical School
- Section Editors
- Martin Weiser, MD
Martin Weiser, MD
- Section Editor — Colorectal Surgery
- Attending Surgeon
- Memorial Sloan Kettering Cancer Center
- Professor of Surgery
- Weill Cornell Medical School
- Lawrence S Friedman, MD
Lawrence S Friedman, MD
- Section Editor — General Gastroenterology
- Professor of Medicine
- Harvard Medical School
- Tufts University School of Medicine
Anal fissure is one of the most common benign anorectal conditions. Trauma to the anoderm with the passage of a hard stool is thought to be a common initiating factor. Persistence of a fissure is typically associated with anal spasm or high anal pressure. The treatment of anal fissure breaks the cyclic anal sphincter spasm, prevents tearing of the anal mucosa, and promotes healing of the fissure.
The majority of anal fissures are treated medically, which is the topic of this discussion [1,2]. Surgical therapy, which is reserved for refractory anal fissures, is discussed in another topic. The clinical manifestations, diagnosis, and prevention of anal fissure are also discussed elsewhere. (See "Anal fissure: Surgical management" and "Anal fissure: Clinical manifestations, diagnosis, prevention".)
Anal fissures can be primary or secondary. Most typical fissures are primary and are caused by local trauma in the context of anal spasm or high anal pressure. Primary anal fissures are most commonly located at the posterior midline, and less commonly at the anterior midline. Secondary, or atypical, anal fissures are caused by another disease process such as Crohn disease and can occur at locations other than the midline. (See "Anal fissure: Clinical manifestations, diagnosis, prevention", section on 'Etiology'.)
Thus, finding of an anal fissure that is not at the midline should prompt an evaluation for Crohn disease, although Crohn-related fissures can also occur at the midline. Other manifestations of perianal Crohn disease include the presence of multiple, recurring, or nonhealing fissures; unusually deep or wide fissures; painless fissures; and perianal skin tags that are hypertrophic, edematous, and tender. Patients with suspected Crohn-related fissures should be referred to a gastroenterologist for further evaluation. (See "Perianal complications of Crohn disease", section on 'Anal fissures'.)
INITIAL MANAGEMENT OF TYPICAL FISSURES
For patients with a typical anal fissure (ie, a single posterior or anterior fissure with no evidence of Crohn disease), we recommend prescribing a combination of supportive measures (fiber, sitz bath, topical analgesic) and one of the topical vasodilators (nifedipine or nitroglycerin) for one month (algorithm 1). In addition, patients who are constipated should receive a stool softener or laxative. The treatment goal is to relax the internal anal sphincter, initiate and maintain atraumatic passage of stool, and relieve pain.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Shub HA, Salvati EP, Rubin RJ. Conservative treatment of anal fissure: an unselected, retrospective and continuous study. Dis Colon Rectum 1978; 21:582.
- Jensen SL. Maintenance therapy with unprocessed bran in the prevention of acute anal fissure recurrence. J R Soc Med 1987; 80:296.
- Nelson RL, Chattopadhyay A, Brooks W, et al. Operative procedures for fissure in ano. Cochrane Database Syst Rev 2011; :CD002199.
- Nelson RL, Thomas K, Morgan J, Jones A. Non surgical therapy for anal fissure. Cochrane Database Syst Rev 2012; :CD003431.
- Parellada C. Randomized, prospective trial comparing 0.2 percent isosorbide dinitrate ointment with sphincterotomy in treatment of chronic anal fissure: a two-year follow-up. Dis Colon Rectum 2004; 47:437.
- American Gastroenterological Association. American Gastroenterological Association medical position statement: Diagnosis and care of patients with anal fissure. Gastroenterology 2003; 124:233.
- Dodi G, Bogoni F, Infantino A, et al. Hot or cold in anal pain? A study of the changes in internal anal sphincter pressure profiles. Dis Colon Rectum 1986; 29:248.
- Jensen SL. Treatment of first episodes of acute anal fissure: prospective randomised study of lignocaine ointment versus hydrocortisone ointment or warm sitz baths plus bran. Br Med J (Clin Res Ed) 1986; 292:1167.
- Ezri T, Susmallian S. Topical nifedipine vs. topical glyceryl trinitrate for treatment of chronic anal fissure. Dis Colon Rectum 2003; 46:805.
- Schouten WR, Briel JW, Auwerda JJ. Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissures. Dis Colon Rectum 1994; 37:664.
- Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum 1989; 32:43.
- Gorfine SR. Topical nitroglycerin therapy for anal fissures and ulcers. N Engl J Med 1995; 333:1156.
- Lund JN, Scholefield JH. A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure. Lancet 1997; 349:11.
- Oettlé GJ. Glyceryl trinitrate vs. sphincterotomy for treatment of chronic fissure-in-ano: a randomized, controlled trial. Dis Colon Rectum 1997; 40:1318.
- Bacher H, Mischinger HJ, Werkgartner G, et al. Local nitroglycerin for treatment of anal fissures: an alternative to lateral sphincterotomy? Dis Colon Rectum 1997; 40:840.
- Altomare DF, Rinaldi M, Milito G, et al. Glyceryl trinitrate for chronic anal fissure--healing or headache? Results of a multicenter, randomized, placebo-controled, double-blind trial. Dis Colon Rectum 2000; 43:174.
- Richard CS, Gregoire R, Plewes EA, et al. Internal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure: results of a randomized, controlled trial by the Canadian Colorectal Surgical Trials Group. Dis Colon Rectum 2000; 43:1048.
- Zuberi BF, Rajput MR, Abro H, Shaikh SA. A randomized trial of glyceryl trinitrate ointment and nitroglycerin patch in healing of anal fissures. Int J Colorectal Dis 2000; 15:243.
- Kennedy ML, Sowter S, Nguyen H, Lubowski DZ. Glyceryl trinitrate ointment for the treatment of chronic anal fissure: results of a placebo-controlled trial and long-term follow-up. Dis Colon Rectum 1999; 42:1000.
- Lund JN, Scholefield JH. Glyceryl trinitrate ointment for chronic anal fissure (letter). Lancet 1997; 349:573.
- Carapeti EA, Kamm MA, Phillips RK. Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects. Dis Colon Rectum 2000; 43:1359.
- Knight JS, Birks M, Farouk R. Topical diltiazem ointment in the treatment of chronic anal fissure. Br J Surg 2001; 88:553.
- Jonas M, Speake W, Scholefield JH. Diltiazem heals glyceryl trinitrate-resistant chronic anal fissures: a prospective study. Dis Colon Rectum 2002; 45:1091.
- Cook TA, Humphreys MM, McC Mortensen NJ. Oral nifedipine reduces resting anal pressure and heals chronic anal fissure. Br J Surg 1999; 86:1269.
- Jonas M, Neal KR, Abercrombie JF, Scholefield JH. A randomized trial of oral vs. topical diltiazem for chronic anal fissures. Dis Colon Rectum 2001; 44:1074.
- ATYPICAL FISSURES
- INITIAL MANAGEMENT OF TYPICAL FISSURES
- Sitz bath
- Topical analgesics
- Stool softener or laxative
- Topical vasodilators
- - Topical nifedipine
- - Topical nitroglycerin
- INTERVAL EVALUATION
- SUBSEQUENT MANAGEMENT OF TYPICAL FISSURES
- Second-line medical therapy
- - Topical diltiazem
- - Topical bethanechol
- - Oral nifedipine
- - Oral diltiazem
- Invasive procedures
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS