Chronic Anal Fissure with Baseline Fecal Incontinence: When First-Line Topical Therapy Has Not Healed the Fissure

This protocol applies to patients with chronic anal fissure who carry an elevated baseline risk for fecal incontinence, or who have clinical characteristics that make standard sphincter-dividing treatment inappropriate. It defines the next management step after first-line topical pharmacologic therapy has failed to achieve fissure healing.

The target population includes patients with baseline fecal incontinence, women with prior obstetrical injuries, patients with inflammatory bowel disease, patients who have undergone previous anorectal operations, and patients with a documented anal sphincter injury — all groups for whom approaches that risk further sphincter compromise require particular caution.

Previous treatment — goal not reached

First-line topical pharmacologic therapy with topical nitrates or topical calcium channel blockers did not achieve healing of the chronic anal fissure. This protocol represents the structured next step after that documented treatment failure.

Next-step treatment approach

The approach at this stage centres on a sphincter-preserving injectable intervention directed at the internal anal sphincter, which may be applied alone or in combination with an adjunct topical agent. Evidence supports its role as a second-line option following failed topical therapy, with data suggesting improved healing outcomes when combined. The full regimen, sequencing, and combination strategy are available in the complete protocol.

Treatment goals

Healing of the anal fissure and at least a 50% reduction in pain score at 3 months.

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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.

Botulinum toxin has similar results compared with topical therapies as first-line therapy for chronic anal fissures and modest improvement in healing rates as second-line therapy following failed treatment with topical therapies.

The use of topical nitroglycerin combined with botulinum toxin has been suggested to improve healing and symptoms in patients with chronic anal fissure.

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