ASCRS Clinical Practice Guideline on Anal Fissure

In 2023, the American Society of Colon and Rectal Surgeons (ASCRS) published updated guidelines on management of anal fissure, which included the following:

Nonoperative treatment of acute anal fissures is safe and should typically be first-line treatment.
Topical nitrates may be employed for treatment, but headache symptoms may limit their efficacy. Calcium-channel blockers (CCBs) are comparably efficacious for chronic anal fissures, have a better side-effect profile, and can be used as first-line treatment.
Botulinum toxin is comparable to topical therapies as first-line treatment for chronic anal fissures and yields modestly improved healing rates as second-line treatment after failed topical therapy.
Lateral internal sphincterotomy (LIS) may be offered to selected patients with chronic anal fissure who have not been treated pharmacologically. It is the treatment of choice for chronic anal fissures in selected patients without baseline fecal incontinence (FI).
Either open or closed techniques may be used for LIS; results are similar. Compared with traditional LIS extending to the dentate line, LIS tailored to fissure length yields similar healing rates and lower FI rates.
Limited short-term outcome data suggest that repeat LIS or botulinum injection for recurrent anal fissure yields good healing rates with a low risk of FI.
Anocutaneous flap is a safe surgical alternative for chronic anal fissure, with healing rates comparable to those of LIS and a lower risk of FI. Addition of an anocutaneous flap to botulinum toxin injection or LIS may decrease postoperative pain and allow for primary wound healing.

ACG Clinical Guideline on Anal Fissure

The 2021 American College of Gastroenterology (ACG) clinical guideline on the management of benign anorectal disorders made the following recommendations for chronic anal fissure^[6]:

In general, management of chronic anal fissure consists of stool softening and spasm reduction for improved regional perfusion.
It is strongly recommended that initial medical treatment of chronic anal fissure be local application of a CCB.
A trial of botulinum toxin A injections is suggested in the setting of failed CCB therapy or as an alternative option to CCB. Another treatment option for chronic anal fissures is nitroglycerine.
LIS is strongly recommended as the surgical treatment of choice for chronic anal fissures refractory to nonsurgical measures.

Questions

Nzimbala MJ, Bruyninx L, Pans A, Martin P, Herman F. Chronic anal fissure: common aetiopathogenesis, with special attention to sexual abuse. Acta Chir Belg. 2009 Nov-Dec. 109 (6):720-6. [QxMD MEDLINE Link].
Farid M, El Nakeeb A, Youssef M, Omar W, Fouda E, Youssef T, et al. Idiopathic hypertensive anal canal: a place of internal sphincterotomy. J Gastrointest Surg. 2009 Sep. 13 (9):1607-13. [QxMD MEDLINE Link].
Grucela A, Salinas H, Khaitov S, Steinhagen RM, Gorfine SR, Chessin DB. Prospective analysis of clinician accuracy in the diagnosis of benign anal pathology: comparison across specialties and years of experience. Dis Colon Rectum. 2010 Jan. 53 (1):47-52. [QxMD MEDLINE Link].
Abramowitz L, Benabderrahmane D, Baron G, Walker F, Yeni P, Duval X. Systematic evaluation and description of anal pathology in HIV-infected patients during the HAART era. Dis Colon Rectum. 2009 Jun. 52 (6):1130-6. [QxMD MEDLINE Link].
[Guideline] Davids JS, Hawkins AT, Bhama AR, Feinberg AE, Grieco MJ, Lightner AL, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures. Dis Colon Rectum. 2023 Feb 1. 66 (2):190-199. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Wald A, Bharucha AE, Limketkai B, Malcolm A, Remes-Troche JM, Whitehead WE, et al. ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol. 2021 Oct 1. 116 (10):1987-2008. [QxMD MEDLINE Link]. [Full Text].
Schiano di Visconte M, Munegato G. Glyceryl trinitrate ointment (0.25%) and anal cryothermal dilators in the treatment of chronic anal fissures. J Gastrointest Surg. 2009 Jul. 13 (7):1283-91. [QxMD MEDLINE Link].
Nitroglycerin rectal ointment (Rectiv) [package insert]. ProStrakan. June 2011. Available at [Full Text].
Samim M, Twigt B, Stoker L, Pronk A. Topical diltiazem cream versus botulinum toxin a for the treatment of chronic anal fissure: a double-blind randomized clinical trial. Ann Surg. 2012 Jan. 255 (1):18-22. [QxMD MEDLINE Link].
Sileri P, Stolfi VM, Franceschilli L, Grande M, Di Giorgio A, D'Ugo S, et al. Conservative and surgical treatment of chronic anal fissure: prospective longer term results. J Gastrointest Surg. 2010 May. 14 (5):773-80. [QxMD MEDLINE Link].
Abd Elhady HM, Othman IH, Hablus MA, Ismail TA, Aboryia MH, Selim MF. Long-term prospective randomised clinical and manometric comparison between surgical and chemical sphincterotomy for treatment of chronic anal fissure. S Afr J Surg. 2009 Nov. 47 (4):112-4. [QxMD MEDLINE Link].
Shao WJ, Li GC, Zhang ZK. Systematic review and meta-analysis of randomized controlled trials comparing botulinum toxin injection with lateral internal sphincterotomy for chronic anal fissure. Int J Colorectal Dis. 2009 Sep. 24 (9):995-1000. [QxMD MEDLINE Link].
Rather SA, Dar TI, Malik AA, Rather AA, Khan A, Parray FQ, et al. Subcutaneous internal lateral sphincterotomy (SILS) versus nitroglycerine ointment in anal fissure: a prospective study. Int J Surg. 2010. 8 (3):248-51. [QxMD MEDLINE Link].
Mousavi SR, Sharifi M, Mehdikhah Z. A comparison between the results of fissurectomy and lateral internal sphincterotomy in the surgical management of chronic anal fissure. J Gastrointest Surg. 2009 Jul. 13 (7):1279-82. [QxMD MEDLINE Link].