Modern perspectives in the treatment of chronic anal fissures

Abstract

Introduction: Anal fissures are commonly encountered in routine colorectal practice. Developments in the pharmacological understanding of the internal anal sphincter have resulted in more conservative approaches towards treatment. Simple measures are often effective for early fissures. Glyceryl trinitrate is well established as a first-line pharmacological therapy. The roles of diltiazem and botulinum, particularly as rescue therapy, are not well understood. Surgery has a defined role and should not be discounted completely.

Methods: Data were obtained from Medline publications citing 'anal fissure'. Manual cross-referencing of salient articles was conducted. We have sought to highlight various controversies in the management of anal fissures.

Findings: Acute fissures may heal spontaneously, although simple conservative measures are sufficient. Idiopathic chronic anal fissures need careful evaluation to decide what therapy is suitable. Pharmacological agents such as glyceryl trinitrate (GTN), diltiazem and botulinum toxin have been subjected to most scrutiny. Though practices in the UK vary, GTN or diltiazem would be suitable as first-line therapy with botulinum toxin used as rescue treatment. Sphincterotomy is indicated for unhealed fissures; fissurectomy has been revisited and advancement flaps have a role in patients in whom sphincter division is not suitable.

Figure 1

Endo-anal ultrasound demonstrating the appearance of the internal anal sphincter (IAS) after manual dilatation for chronic anal fissure. The white arrows indicate the defects in the IAS.

Figure 2

Endo-anal ultrasound demonstrating the appearance of the internal anal sphincter (IAS) after lateral sphincterotomy for chronic anal fissure. The white arrow indicates the defect in the IAS.

Figure 3

Treatment algorithm for chronic anal fissures. If patients heal, a follow-up out-patient appointment should be considered.