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Anal fissure: Medical management

Elizabeth Breen, MD
Ronald Bleday, MD
Section Editors
Martin Weiser, MD
Lawrence S Friedman, MD
Deputy Editor
Wenliang Chen, MD, PhD


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'.)


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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Literature review current through: Sep 2016. | This topic last updated: May 18, 2016.
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