Anal fissure: Medical management
- Elizabeth Breen, MD
Elizabeth Breen, MD
- Assistant Professor of Surgery
- Harvard Medical School
- 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
- Professor of Surgery
- Weill Cornell Medical College
- Memorial Sloan Kettering Cancer Center
- 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.
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- ATYPICAL FISSURES
- INITIAL MANAGEMENT OF TYPICAL FISSURES
- Sitz bath
- Topical analgesics
- Stool softner 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