Approach
The goal of treatment should be rapid and effective symptom relief. Acute and chronic fissures are treated in much the same way, because it is merely the duration of symptoms that distinguishes them. Initial consideration should be given to the cause of the fissure, such as constipation or opiate use, and appropriate action taken, such as dietary modification or reassessment of opiate use.
Initial treatment
Patients should be advised to follow conservative measures consisting of a high-fibre diet, increased fluid intake, sitz baths, and, in more severe cases, stool softeners and analgesics. An initial trial of this conservative treatment alone is appropriate in most cases, particularly for acute anal fissures.[18][19] Additional treatment with topical nitrates or calcium channel blockers is appropriate in most instances. Both have been shown to be effective in treating anal fissure, and the choice should depend upon local licensing, availability, costs, and contraindications.[20] Treatment with diltiazem has become a common first choice for most patients because of the high incidence of dose-limiting headaches following topical nitrates.[19] A topical formulation of diltiazem may need to be compounded by a pharmacist if a proprietary product is unavailable.
It is essential that topical treatment be continued for 6 to 8 weeks to allow re-epithelialisation of the fissure.[4] It is common for patients to stop treatment after early improvement of symptoms, but early relapse often follows. On review at 6 to 8 weeks, history and examination are repeated.[4] Healed patients may be discharged with advice to maintain a high-fibre diet, which decreases the risk of recurrence. If a fissure is unhealed, but the patient is reporting notable symptomatic improvement, a further 6 to 8 weeks topical therapy may be offered. If unhealed after this, referral to secondary care should be made. Unhealed symptomatic patients should be referred to secondary care after the initial 6 to 8 weeks.
Resistant fissures
If a fissure is resistant to topical treatments, diagnosis of primary idiopathic fissure should be confirmed by careful history and physical examination (under anaesthesia if necessary). Once diagnosis is confirmed and no other pathology identified, the relative merits of surgery, botulinum toxin, and further topical treatment should be discussed with the patient in the context of their history, risk of incontinence, intensity of symptoms, and preferences. This should involve an informed discussion recognising that the rate of fissure healing is significantly higher with surgery, albeit with the slight risk of reduction in continence.[21][22]
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If the patient opts for further topical treatment, those unhealed after a further 6 to 8 week course should be offered surgery. If an underlying disease is identified then this should be treated; the fissure may heal as the underlying condition improves.
In 1% to 5% of cases, fissures remain unhealed after surgery.[23] Further investigation, such as anal manometry and endoanal ultrasound, should be performed to ensure the adequacy of the sphincterotomy and also to exclude pre-existing sphincter defects before undertaking any additional muscular division.Consideration should also be given to other conditions that could be causing the fissure, such as HIV infection, Crohn's disease, sarcoidosis, tuberculosis, syphilis, and other sexually transmitted infections.[16] Anal advancement flaps may be considered as an alternative to sphincterotomy in some instances. Although the failure rate is higher, there is essentially no risk of postoperative incontinence. High-risk female patients, or patients with baseline decreased sphincter tone, should be offered this surgical option.[19][24]
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