Management of Anal Fissures

This guideline offers evidence-based recommendations on the targeted levels of Clinical practice guidelines and provide healthcare professionals with practical guidance on the diagnosis and treatment of anal fissure.

·       Non-operative treatment of acute anal fissures continues to be safe, has few side effects, and should typically be recommended as the first-line treatment, (Strong recommendation).

·       Treatment of anal fissures with topical nitrates is recommended, although side effects may limit their efficacy, (Strong recommendation).

·       The use of calcium channel blockers for chronic anal fissures has a similar efficacy to topical nitrates, with a superior side effect profile, and can be recommended as first-line treatment, (Strong recommendation).

·       We recommend Botulinum toxin as second-line therapy following treatment with topical therapies in treatment of chronic anal fissure, (Conditional recommendation).

·       We recommend internal sphincterotomy, (IS) in the treatment of chronic anal fissures as first line of treatment or as a second line of treatment after failure of medical treatment, (Strong recommendation).

·       Laser therapy is not routinely recommended for the treatment of anal fissures due to limited evidence supporting its efficacy in this context, (Good practice statement).

·       We recommend to repeat IS or botulinum toxin injection for recurrent anal fissure, (conditional recommendation).

·       In recurrent anal fissure the use of an ano-cutaneous flap may be recommended to decreases postoperative pain and allows for primary wound healing, (conditional recommendation).

·       In the presence of multiple anal fissures or abnormal sites of fissure or recurrent fissure, we recommend excluding other causes of anal fissure: such as Crohn’s disease or sexually transmitted diseases, (conditional recommendation).