Management of Recurrent Anal Fissures

Introduction to Treatment Options

The American College of Surgeons recommends non-operative management as first-line treatment for anal fissures, including recurrent ones, which includes increasing fiber intake and water consumption, warm sitz baths to relax the internal anal sphincter, and topical analgesics for pain control 1, 2
The American Gastroenterological Association suggests that 50% of fissures heal with conservative measures alone within 10-14 days 2, 3

Calcium channel blockers, such as diltiazem or nifedipine, achieve healing rates of 65-95% and are preferred over nitroglycerin due to fewer side effects 1, 2, 3
Nitroglycerin achieves healing rates of only 25-50% 4, 3

The American Society of Colon and Rectal Surgeons recommends adding topical therapy, with calcium channel blockers as the first choice, if conservative measures fail after 2 weeks 1, 2
The European Society of Coloproctology suggests using 0.2% glyceryl trinitrate ointment as a second choice if calcium channel blockers are unavailable 1, 4, 3
Botulinum toxin injection shows 75-95% cure rates with low morbidity if topical therapy fails 4
Lateral internal sphincterotomy is reserved for fissures that fail all conservative and medical management 1, 4

Manual dilatation should never be performed as it carries 30% temporary and 10% permanent incontinence rates 1, 2, 3
Rushing to surgery for a second fissure should be avoided, and the conservative approach should be repeated first 1, 2