Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

on presentation

1st line – conservative treatment alone

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ACUTE
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on presentation
1st line – 

conservative treatment alone

Conservative treatment consists of a high-fiber diet, adequate fluid intake, sitz baths, and topical analgesia. Stool softeners can be useful to make defecation less uncomfortable. This treatment is appropriate for most cases, particularly acute anal fissures.[18][19]

Consider – topical diltiazem

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ACUTE
|
on presentation
Consider – 

topical diltiazem

Treatment recommended for SOME patients in selected patient group

Treatment with diltiazem has become a common first choice for most patients because of the high incidence of dose-limiting headaches following topical nitroglycerin.[19]

Diltiazem has similar efficacy to topical nitroglycerin, with a superior side effect profile.[19] A topical formulation of diltiazem may need to be compounded by a pharmacist if a proprietary product is unavailable.

Analgesia may be prescribed for patients in extreme pain.

Primary options

diltiazem topical: (2%) apply small amount to the affected area(s) twice to three times daily for 6-8 weeks

Consider – topical nitroglycerin

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ACUTE
|
on presentation
Consider – 

topical nitroglycerin

Treatment recommended for SOME patients in selected patient group

Nitroglycerin is widely used. It can be used in children and adults, but should be avoided in pregnant and lactating women.

Duration of therapy is important as relief of symptoms may occur quickly, but healing takes a minimum of 6 weeks.[4]

Some patients experience a headache due to nitroglycerin entering the bloodstream and causing cerebral vasodilatation. If this happens, acetaminophen will ease symptoms. These symptoms usually improve after a few days and patients should be encouraged to persist with treatment.

Analgesia may be prescribed for patients in extreme pain.

Primary options

nitroglycerin intra-anal: (0.2 to 0.4%) apply small amount to the affected area(s) twice daily for 6 weeks

resistant fissures

1st line – onabotulinumtoxinA

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ACUTE
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resistant fissures
1st line – 

onabotulinumtoxinA

Formerly known as botulinum toxin type A.

Used after failure of topical treatment.[25][26]

It is particularly useful in female patients about whom there is concern over the integrity of the anal sphincters following childbirth.

Consult specialist for guidance on dose.

1st line – surgical sphincterotomy

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ACUTE
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resistant fissures
1st line – 

surgical sphincterotomy

Surgical sphincterotomy is required if symptoms persist and the patient is unresponsive to initial therapies.[19][27]​​

Sphincterotomy carries a risk of fecal leakage and incontinence, particularly in women who have a short or weak anal sphincter (e.g., childbirth injuries). These patients should have anal manometry and endoanal ultrasound prior to any surgical insult to the anal sphincter.

Patients being consented for sphincterotomy must be counseled with regard to the risk of incontinence. This may be a transient symptom in a competently performed sphincterotomy, but patients should be warned of impairment of minor degrees of continence (flatus/mucus/liquid stool) in up to 30% of cases.[3][27][28]

2nd line – anal advancement flap

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ACUTE
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resistant fissures
2nd line – 

anal advancement flap

Anal advancement flaps have a higher failure rate than sphincterotomy but a lower risk of incontinence. This should therefore be considered as a surgical alternative in selected high-risk cases.[19][24]​​​​

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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