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Anal Fistulas and Fissures Treatment & Management

  • Author: Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE; Chief Editor: Robert E O'Connor, MD, MPH  more...
Updated: Dec 19, 2014

Approach Considerations

Anal fissure

Anal fissures can cause a vicious cycle in which the patient, in anticipation of pain associated with bowel movement, resists the urge to defecate, causing stools to become larger and harder, resulting in more pain with defecation. Treatment should be focused on breaking this cycle to allow healing. If the patient is having a great deal of pain, a topical anesthetic may be applied. Diet modification to soften stools is also indicated in patients with anal fissures. Patients should increase fruits, vegetables, and soluble and insoluble fibers in their diets and increase fluid intake to treat the acute phase and to prevent recurrence. Bulking agents such as psyllium may be prescribed. Approximately half of all anal fissures heal with nonoperative therapy within 2-4 weeks.

Use the WASH regimen in treatment of anal fissures, as follows:

  • W arm water; shower or sitz bath after bowel movement
  • A nalgesics
  • S tool softener
  • H igh-fiber diet

Medications may also be prescribed for anal fissures, such as topical nitrates, calcium channel blockers, and onabotulinumtoxinA injections, and are considered first-line therapy.[13] These medications reduce anal sphincter tone, which, in turn, increases anodermal blood flow. When conservative treatment fails, surgical therapy may be an option to treat anal fissures.

Historically, surgical therapy was common for the treatment of anal fissures and is considered superior to nonoperative therapies. However, due to the risk of complications, including incontinence, surgical therapy is often reserved when conservative treatment fails to heal anal fissures.

Anal fistula

Treatment of anal fistulas depends on (1) the location of the fistula, (2) evidence of sepsis or a large abscess, or (3) worrisome findings on physical examination. If an abscess is present, drainage is indicated. Intravenous antibiotics, antipyretics, and analgesics are provided as needed. However, simple rectal abscesses do not typically need antibiotics.[14] If the patient also has sepsis, intravenous fluids or a pressor may be necessary. Depending on the presence of systemic symptoms and the condition of the patient, surgery may be necessary.

For anal fistulas, outpatient follow-up with a surgeon is indicated if consultation did not take place at the time of presentation. Surgical therapy is often indicated for healing of an anal fistula. The surgical approach is dependent on whether the fistula is simple or complex, as well as the risk of complications such as incontinence. A gastroenterologist should be consulted if inflammatory bowel disease is suspected. Asymptomatic anal fistulas from Crohn disease are not managed by surgery. However, if the patient is symptomatic, surgical management should be considered.

Antibiotics should be reserved for those with overlying cellulitis or those with sepsis. Otherwise, symptomatic treatment with analgesics should be considered.

In an open-label, single-arm clinical study by de la Portilla et al, local injections of expanded adipose-derived allogeneic mesenchymal stem cells proved beneficial for patients with perianal fistulas associated with Crohn disease. The study involved 24 patients, with investigators finding that in 69.2% of cases, the number of draining fistulas was reduced, while in 56.3% of patients, the treated fissures closed completely, and in 30% of cases, all existing fistula tracts completely closed.[15]


Consensus guidelines from a working group of the World Congress of Gastroenterology call for a multidisciplinary approach to the management of perianal fistulas associated with Crohn disease. The guidelines list surgical drainage of the abscesses as first-line treatment prior to starting immunosuppressive therapy. Definitive fistula repair with surgical treatment such as fistulotomy, ligation of the intersphincteric fistula tract (LIFT), or the use of mucosal advancement flaps, plugs, or fibrin glue should be considered only if there is no luminal inflammation. The guidelines also state that anti-tumor necrosis factor can provide first-line medical therapy, with an option being to combine this treatment with the use of antibiotics and/or thiopurines.[16]


Pharmacologic Treatment of Anal Fissures

Calcium channel blockers

Oral and topical calcium channel blockers (diltiazem and nifedipine) have been shown to be effective treatment options for anal fissures. Calcium channel blockers work by decreasing resting anal pressures. In a recent review, calcium channel blockers were shown to be as effective as topical nitrates. Adverse effects such as headaches are common, especially with the use of oral calcium channel blockers. {refFollowupInOutPatientMeds}[[17] 17] Oral calcium channel blockers have been shown to yield decreased healing rates compared with topical calcium channel blockers, as well as higher rates of adverse effects.[18]

Topical nitrates

Topical nitrates have been shown to be effective in the treatment of anal fissures. It is applied directly to the anus and decreases anal resting pressures. In a Cochrane review, topical nitrates were better than placebo in healing anal fissures (48.9% vs 35.5%). However, late recurrence was common (>50%) and headaches occurred frequently, causing cessation of therapy (up to 30%).[17]

Different dosing has also been studied, from 0.05% to 0.4%, without a difference in healing rates.[19, 20, 21] Topical nitrates have also been compared with nitroglycerin patches applied to a remote area, with similar cure rates.[22]

One small randomized controlled trial between topical diltiazem gel (2%) or glyceryl trinitrate ointment (0.2%) showed a healing rate of 92% with diltiazem compared with 60% with glyceryl trinitrate (P < .001).[23] Adverse effects were more common with glyceryl trinitrate.


OnabotulinumtoxinA is used typically to treat muscle hypertonia and cosmetic disorders. Typically, onabotulinumtoxinA is injected into the internal sphincter, reducing hypertonia. Various dosing schemes have been used, and it is typically injected on both sides of the anal fissure. OnabotulinumtoxinA has been shown to be as effective as topical nitrates, but with fewer adverse effects, including headache, and can be an alternative to surgery.[17, 24] Botulism toxin has not been shown to be an effective treatment when other medical therapies have failed.[25]

Topical analgesics

Topical lidocaine can be used as an anesthetic to help relieve pain associated with anal fissures. Clove oil has also been studied and shows some promise in providing analgesia.[26]


Surgical Treatment of Chronic Anal Fissures

Chronic anal fissures frequently require surgical treatment.[12] Surgical procedures involve anal dilation, flap and fissurectomy, or cutting the lateral internal sphincter.

Open lateral internal sphincterotomy (LIS) is considered the treatment of choice for chronic anal fissure and can be performed either opened or closed.[13, 27, 28] It reduces the hypertonia of the internal anal sphincter, increases anodermal blood flow, decreases pain, and allows the fissure to heal. However, traditional LIS has been associated with relatively high rates of incontinence.

Other surgical techniques have been described, including a more tailored approach, which showed lower rates of complications but higher rates of treatment failure.[29, 30, 31] LIS has been shown to have a higher rate of cure than anal dilation. Data for subcutaneous fissurectomy with anal advancement flap are limited.[13]


Surgical Treatment of Anal Fistulas

For simple anal fistulas, fistulotomy with or without marsupialization is recommended.[14] In the presence of an abscess with anal fistula, incision and drainage along with fistulotomy may be considered. This is associated with decreased recurrence (relative risk, 0.17; 95% confidence interval, 0.09-0.32; P < .001) but increased risk of continence disturbance.[32] Fibrin glue has also been studied, with the advantage of less risk of incontinence. However, success rates have been reported lower than those for fistulotomy (41.7%).

For complex fistulas, debridement and fibrin glue or fistula plug may be used. Success rates for fibrin glue range from 10-67%. Although it has a relatively low success rate, recent guidelines suggest that fibrin glue may be used as first-line therapy.[14] Likewise, variable success has been reported with fistula plugs. One small trial described a success rate of 72.7% with the use of the Gore Bio-A fistula plug.[33] Endoanal advancement flaps also have variable success rates for the treatment of complex fistulas.

Ligation of intersphincteric fistula tract (LIFT) has also been described, with long-term success rates (>12 months) of 62%.[34] In this small study, fistula tract lengths greater than 3 cm were noted to have a higher rate of failure with LIFT (odds ration, 0.55; 95% confidence interval, 0.34-0.88).

In some cases, staged surgery is needed to repair an anal fistula.

Contributor Information and Disclosures

Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE Medical Director, Department of Emergency Medicine, Sentara Norfolk General Hospital; Associate Professor, Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School

Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians, American College of Healthcare Executives, American Institute of Ultrasound in Medicine, Emergency Nurses Association, Medical Society of Virginia, Norfolk Academy of Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


Ingrid Legall, MD Assistant Professor, Department of Emergency Medicine, Florida Hospital-Flagler

Ingrid Legall, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Association for Physician Leadership, American Heart Association, Medical Society of Delaware, Society for Academic Emergency Medicine, Wilderness Medical Society, American Medical Association, National Association of EMS Physicians

Disclosure: Nothing to disclose.


Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Eugene Hardin, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Anal fistulas and fissures. This patient reported constipation.
Anal fissure present in a patient with Crohn disease.
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