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Conservative management:

  • initial approach in the treatment of anal fissures is non-operative. An acute anal fissure may heal spontaneously or in response to medical therapy with warm baths, stool softeners, bulk laxatives, analgesics, topical anaesthetics and re-assurance
  • introduction of more bran into the diet together with laxatives and analgesic suppositories
  • some suggest the use of a plastic anal dilator - however others state that regular anal dilatation to treat anal fissures is not recommended (1)
  • topical glyceryl trinitrate may be beneficial
  • topical formulation of diltiazem (Topical 2% diltiazem)
    • valid alternative to GTN
    • data to suggest that topical diltiazem heals GTN-resistant fissures (2)
  • botulinum toxin injections may be used as an alternative to treatment with GTN (or in patients in whom GTN fails)
  • a review suggest that topical GTN or diltiazem would be suitable as first-line therapy with botulinum toxin used as rescue treatment (2)

Surgical management - this can bring immediate relief:

  • internal sphincterotomy:
    • in studies with short term follow-up the healing rate was 92-100%
  • manual dilatation:
    • reduces sphincter pressure
    • results in healing in 40-70%
    • results in incontinence in 25-75%
    • is rarely indicated


Last reviewed 09/2020