Clinical Scenario

This protocol addresses patients with a chronic anal fissure that displays one or more stigmata of chronicity — such as a hypertrophied anal papilla, a sentinel tag, or exposed internal anal sphincter fibers at the fissure base — in the absence of baseline fecal incontinence.

Previous Treatment — Goals Not Met

This is the recommended next step when botulinum toxin injection into the internal anal sphincter (used alone or combined with topical nitroglycerin) has not achieved healing of the fissure or at least a 50% reduction in pain score by 3 months.

Next-Step Approach (Partial Overview)

The protocol calls for a surgical procedure targeting the internal anal sphincter, with the extent of the intervention calibrated to the specific anatomy of the fissure. The treatment goal is complete healing of the chronic anal fissure. Full operative technique, selection criteria, and follow-up guidance are in the complete protocol.

References

DOI: 10.1097/DCR.0000000000002664

Fissures of a longer duration will often manifest 1 or more stigmata of chronicity, including a hypertrophied anal papilla at the proximal aspect of the fissure, a sentinel tag at the distal aspect of the fissure, and/or exposed internal anal sphincter muscle within the base of the fissure.

LIS is the treatment of choice for chronic anal fissures in selected patients without baseline FI.

LIS tailored to the length of the fissure yields similar healing rates but decreased FI rates compared with traditional LIS extending to the dentate line.

Open and closed techniques of LIS yield similar results and either technique may be used.

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Chronic Anal Fissure with Stigmata of Chronicity After Failed Botulinum Toxin Injection