Anal Fissure Guidelines

Updated: Mar 29, 2023
  • Author: Lisa Susan Poritz, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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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.