Highlights & Basics
- Anal fissure causes severe pain on defecation, often described as "like passing broken glass." The pain may continue for 1 to 2 hours and can also be burning in nature.
- A small amount of fresh red blood is often passed on the stool and is also seen when wiping.
- On examination of the anus, there is often marked spasm of the sphincter muscles, with significant tenderness often precluding digital examination.
- Initial treatment should include either topical nitroglycerin or diltiazem, along with a program of supportive care.
- Resistant or chronic fissures may benefit from injection with onabotulinumtoxinA, and most cases can be cured by surgical sphincterotomy or anal advancement flap.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Citations
Gilani A, Tierney G. Chronic anal fissure in adults. BMJ. 2022 Jan 12;376:e066834.
Lund JN, Nystrom PO, Coremans G, et al. An evidence-based treatment algorithm for anal fissure. Tech Coloproctol. 2006 Oct;10(3):177-80.[Abstract]
American Gastroenterological Association. American Gastroenterological Association medical position statement: diagnosis and care of patients with anal fissure. Gastroenterology. 2003 Jan;124(1):233-4.[Full Text]
Davids JS, Hawkins AT, Bhama AR, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anal fissures. Dis Colon Rectum. 2023 Feb 1;66(2):190-9.[Full Text]
Menteş BB, Irkörücü O, Akin M, et al. Comparison of botulinum toxin injection and lateral internal sphincterotomy for the treatment of chronic anal fissure. Dis Colon Rectum. 2003 Feb;46(2):232-7.[Abstract]
1. Ayatunde AA, Debrah SA. Current concepts in anal fissures. World J Surgery. 2006;30:2246-60.[Abstract]
2. Lund JN, Scholefield JH. Aetiology and treatment of anal fissure. Br J Surg. 1996;83:1335-1344.[Abstract]
3. Collins EE, Lund JN. A review of chronic anal fissure management. Tech Coloproctol. 2007 Sep;11(3):209-23.[Abstract]
4. Gilani A, Tierney G. Chronic anal fissure in adults. BMJ. 2022 Jan 12;376:e066834.
5. Mapel DW, Schum M, Von Worley A. The epidemiology and treatment of anal fissures in a population-based cohort. BMC Gastroenterol. 2014 Jul 16;14:129.[Abstract][Full Text]
6. Schouten WR, Briel JW, Auwerda JJ, et al. Ischaemic nature of anal fissure. Br J Surg. 1996 Jan;83(1):63-5.[Abstract][Full Text]
7. Lund JN. Nitric oxide deficiency in the internal anal sphincter of patients with chronic anal fissure. Int J Colorectal Dis. 2006;21:673-675.[Abstract]
8. Cross KL, Massey EJ, Fowler AL, et al; ACPGBI. The management of anal fissure: ACPGBI position statement. Colorectal Dis. 2008 Nov:10 Suppl 3:1-7.[Full Text]
9. Klosterhalfen B, Vogel P, Rixen H, et al. Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum. 1989;32:43-52. [Abstract]
10. Lund JN, Binch C, McGrath J, et al. Topographical distribution of blood supply to the anal canal. Br J Surg. 1999;86:496-498.[Abstract]
11. Lu Y, Kwaan MR, Lin AY. Diagnosis and treatment of anal fissures in 2021. JAMA. 2021 Feb 16;325(7):688-9.
12. Lund JN, Scholefield JH. A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure. Lancet. 1997 Jan 4;349(9044):11-4.[Abstract]
13. Nelson RL, Thomas K, Morgan J, et al. Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012;(2):CD003431.[Abstract][Full Text]
14. Jensen SL. Diet and other risk factors for fissure-in-ano. Prospective case control study. Dis Colon Rectum. 1988;31:770-773.[Abstract]
15. Lock MR, Thompson JPS. Fissure-in-ano: the initial management and prognosis. Br J Surg. 1977 May;64(5):355-8.[Abstract]
16. Lund JN, Nystrom PO, Coremans G, et al. An evidence-based treatment algorithm for anal fissure. Tech Coloproctol. 2006 Oct;10(3):177-80.[Abstract]
17. Gough MJ, Lewis A. The conservative treatment of fissure-in-ano. Br J Surg. 1983;70:175-176.[Abstract]
18. American Gastroenterological Association. American Gastroenterological Association medical position statement: diagnosis and care of patients with anal fissure. Gastroenterology. 2003 Jan;124(1):233-4.[Full Text]
19. Davids JS, Hawkins AT, Bhama AR, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anal fissures. Dis Colon Rectum. 2023 Feb 1;66(2):190-9.[Full Text]
20. Altomare DF, Binda GA, Canuti S, et al. The management of patients with primary chronic anal fissure: a position paper. Tech Coloproctol. 2011 Jun;15(2):135-41.[Abstract][Full Text]
21. Nasr M, Ezzat H, Elsebae M. Botulinum toxin injection versus lateral internal sphincterotomy in the treatment of chronic anal fissure: a randomized controlled trial. World J Surg. 2010 Nov;34(11):2730-4.[Abstract]
22. Menteş BB, Irkörücü O, Akin M, et al. Comparison of botulinum toxin injection and lateral internal sphincterotomy for the treatment of chronic anal fissure. Dis Colon Rectum. 2003 Feb;46(2):232-7.[Abstract]
23. Lewis TH, Corman ML, Prager ED, et al. Long term results of open and closed sphincterotomy for anal fissure. Dic Colon Rectum. 1988 May;31(5):368-71.[Abstract]
24. Jonas M, Scholefield JH. Anal fissure. Gastroenterol Clin North Am. 2001 Mar;30(1):167-81.[Abstract]
25. Shao WJ, Li GC, Zhang ZK. Systematic review and meta-analysis of randomized controlled trials comparing botulinum toxin injection with lateral internal sphincterotomy for chronic anal fissure. Int J Colorectal Dis. 2009 Sep;24(9):995-1000.[Abstract]
26. Schmidt-Lauber M. Blind, randomized clinical study on botulinum toxin in comparison with isosorbide dinitrate ointment for the treatment of anal fissures. Coloproctology. 2010;32:191-2.
27. Nelson RL, Chattopadhyay A, Brooks W, et al. Operative procedures for fissure in ano. Cochrane Database Syst Rev. 2011 Nov 9;2011(11):CD002199.[Abstract][Full Text]
28. Casillas S, Hull TL, Zutshi M, et al. Incontinence after a lateral internal sphincterotomy: are we underestimating it? Dis Colon Rectum. 2005 Jun;48(6):1193-9.[Abstract]
29. Yilmaz G, Tanrikulu Y. Short-term results of platelet-rich plasma in the treatment of chronic anal fissure: randomized controlled clinical study. Dis Colon Rectum. 2021 Jun 1;64(6):714-23.[Abstract]
30. Ebrahimibagha H, Zeinalpour A. Platelet-rich plasma improves acute and chronic anal fissure, a randomized control trial. Wound Repair Regen. 2023 Sep-Oct;31(5):655-62.[Abstract]
31. Alvandipour M, Ala S, Khalvati M, et al. Topical minoxidil versus topical diltiazem for chemical sphincterotomy of chronic anal fissure: a prospective, randomized, double-blind, clinical trial. World J Surg. 2018 Jul;42(7):2252-8.[Abstract][Full Text]
32. Youssef T, Youssef M, Thabet W, et al. Randomized clinical trial of transcutaneous electrical posterior tibial nerve stimulation versus lateral internal sphincterotomy for treatment of chronic anal fissure. Int J Surg. 2015;22:143-148.[Abstract]
33. Wald A, Bharucha AE, Limketkai B, et al. ACG clinical guidelines: management of benign anorectal disorders. Am J Gastroenterol. 2021 Oct 1;116(10):1987-2008.[Abstract][Full Text]
34. Tarasconi A, Perrone G, Davies J, et al. Anorectal emergencies: WSES-AAST guidelines. World J Emerg Surg. 2021 Sep 16;16(1):48.[Abstract][Full Text]
35. Miller AS, Boyce K, Box B, et al. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis. 2021 Feb;23(2):476-547.[Abstract][Full Text]
