Page 5 - 01- Anal Fissure

Lateral internal sphincterotomy (LIS) involves division of the internal sphincter muscle and is
the surgical procedure of choice (95% healing) (1)[A].
– Risk for fecal or flatus incontinence: up to 45% short term, up to 6–8% long term
– Open and closed techniques have similar results and are equally acceptable (1)[A].
– May be repeated for recurrent fissures with similar outcomes (1)[C]
– Not typically performed on women of childbearing potential due to increased risk of fecal
incontinence with or without subsequent obstetrical injury (1)
Anocutaneous flap safe alternative to LIS in patients without anal hypertonia with less
incontinence but lower healing rates (1)[B]
Botulinum toxin injections also first-line treatment; less effective (60–80% healing) than
surgery but fewer complications (4)[C]
– Risk for fecal or flatus incontinence: 18% short term, no long term
– May be repeated as needed with same efficacy; lower doses as effective as higher doses
with lower rates of complications including incontinence and recurrence (5)[A]
– Higher doses combined with fissurectomy may be as effective as surgical sphincterotomy
(6)[C].
Controlled pneumatic balloon dilation may be used by gastroenterologists if surgical referral
not available; should not be used first line as benefits are not well documented. Uncontrolled
manual dilation is no longer recommended (5)[C].

ONGOING CARE

DIET
High fiber (>25 g/day; augment with daily fiber supplements); increase fluid intake, decrease
caffeine

PATIENT EDUCATION
Avoid prolonged sitting or straining during bowel movements; drink plenty of fluids; avoid
constipation; lose weight if obese.
Avoid use of triple antibiotic ointment and long-term use of steroid creams to anal area.
Use a finger cot or glove when applying nitroglycerin ointment, and apply first dose before
bedtime to minimize side effects.
Topical medications should be applied directly to anal verge; no need to insert rectally.
Alternative medicine therapies (hibiscus extract, clove oil, anal self-massage) need further
study before they can be recommended as first-line treatment.
PROGNOSIS
Most acute fissures heal within 6 weeks with conservative therapy. Medical therapy is less likely
to be successful for chronic anal fissures (40% failure rate) but should remain first-line treatment.
COMPLICATIONS
Chronic fissure is a complication of nonhealing acute fissure.
Recurrence is a common complication especially when underlying cause is not addressed.
Abscess and fistula formation are less common complications.
Fecal and flatus incontinence are primarily associated with surgery (5–45% postop), which
may become permanent (up to 8% long term, primarily to flatus).