Treatment

• First‑line treatment for most anal fissures

• Includes:

  • Dietary improvement (e.g., adequate ingestion of dietary fiber and water)

  • Stool softeners (e.g., docusate)

  • Anti‑inflammatory and analgesic creams and/or suppositories (e.g., 2% lidocaine jelly)

  • Sitz baths

  • Local anesthetic injection

  • Topical vasodilator therapy: calcium channel blocker gel (e.g., nifedipine) or glyceryl trinitrate ointment (GTN)

• Persistent symptoms despite > 8 weeks of conservative therapy → endoscopy to exclude IBD

• If IBD is excluded, then the patient should receive definitive surgical treatment.

• Botulinum toxin A (BTX) injection into the internal anal sphincter

• Indicated when conservative treatment is unsuccessful

• The risk of fecal incontinence (e.g., high in multiparous or elderly patients) determines the type of surgical intervention.

  • Low risk

    • Sphincterotomy (e.g., lateral internal sphincterotomy)

    • Anal dilatation (although there is a high risk of fecal incontinence with this procedure)

  • High risk

    • Anal advancement flap

    • Fissurectomy (excision of the fissure)

Conservative therapy is preferred because of the risk of incontinence!