Not all patients with chronic anal fissure are suitable candidates for the same interventions. When fecal incontinence is present at baseline, or when the patient's history places them at heightened risk from sphincter-disrupting procedures, the treatment strategy must be tailored accordingly.

Who this protocol applies to

Patients with chronic anal fissure in whom the standard surgical approach is excluded or requires careful reconsideration due to:

Baseline fecal incontinence
Women with prior obstetrical injuries
Inflammatory bowel disease
Previous anorectal operations
Documented anal sphincter injury

First-line approach

First-line management in this population relies on topical pharmacologic therapy. The complete protocol details the specific agents indicated, their comparative evidence, and the relevant clinical considerations for this setting.

Full regimen, agent selection, and evidence available in the complete protocol below.

References

DOI: 10.1097/DCR.0000000000002664

Those in whom LIS may be excluded as first-line therapy include women with prior obstetrical injuries, patients with IBD, patients who have undergone previous anorectal operations, and patients with a documented anal sphincter injury.

For patients with chronic anal fissure who are at higher risk for FI after LIS, an alternative sphincter-preserving surgical approach is an anocutaneous (dermal V-Y or house) flap, which has been described using a variety of techniques.

Anal fissures may be treated with topical nitrates, although headache symptoms may limit their efficacy.

Compared with topical nitrates, the use of calcium channel blockers for chronic anal fissures has similar efficacy, with a superior side-effect profile, and can be used as first-line treatment.

Topical nitroglycerin is associated with healing in approximately 50% of chronic anal fissures.

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Chronic Anal Fissure with Baseline Fecal Incontinence or Elevated Sphincter Risk

References