Management of Anal Fissures

Section1.  Non-operative treatment of acute anal fissures:

·  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, moderate certainty evidence⁽⁶⁾).

Section2: Treatment  of chronic anal fissures:

·  Treatment of anal fissures with topical nitrates is recommended, although side effects may limit their efficacy, (Strong recommendation, high certainty evidence ⁽⁶⁾).

·  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, high certainty evidence⁽⁶⁾ ).

Section3: Botulinum toxin

·  We recommend Botulinum toxin as second-line therapy following treatment with topical therapies in treatment of chronic anal fissure, (Conditional recommendation, very low certainty evidence ⁽⁶⁾).

 Section4: Surgical treatment of anal fissures:

·   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, high certainty evidence ⁽⁶⁾).

Section 5: Laser fissurectomy

·  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).    

Section 6:  Recurrent chronic anal fissures:

·   We recommend to repeat IS or botulinum toxin injection for recurrent anal fissure, (conditional recommendation, low certainty evidence ⁽⁶⁾).

·  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, low certainty evidence ⁽⁶⁾).

Section 7:  Miscellaneous causes of anal fissures:

·  In the presence of multiple anal fissures or abnormal sites of fissure or recurrent fissure, we recommend to exclude other causes of anal fissure: such as Crohn’s disease or sexually transmitted diseases, (conditional recommendation, low certainty evidence ⁽⁶⁾).