Treatment is with warm saline sitz baths, analgesics and 15 g bran or psyllium fibre orally each day for 3 months.
In a milder case of anal fissure the discomfort is slight, anal spasm is a minor feature and the onset is acute.
Xyloproct® suppositories or ointment
High-residue diet (consider the addition of unprocessed bran)
Avoidance of constipation with hard stools (aim for soft bulky stools)
Glyceryl trinitrate ointment (Nitro-bid® 2%) diluted 1 part with 9 parts white soft paraffin applied to the lower anal canal 2 to 3 times daily. A commercial preparation is Rectogesic® ointment—apply 3 times daily for 6 weeks or until healed. Warn the patient about headache and lightheadedness
Some clinics favour the topical application of 2% diltiazem cream1
More severe chronic fissures
The feature here is a hyperactive anal sphincter, and a practical procedure is necessary to solve this painful problem. Methods include:
Method 1: Digital anal dilatation
Under general anaesthesia (or even adequate local anaesthesia), undertake four-finger (maximum) anal dilatation for 4 minutes. This is effective, but is usually followed by a brief period of incontinence.
Anal dilatation under general anaesthesia is a most appropriate treatment for children with anal fissures.
Method 2: Inject botulinum toxin into the sphincter
Several studies indicate excellent results when botulinum toxin is injected into the surrounding internal sphincter. Its availability and considerable cost are limiting factors.
Method 3: Lateral sphincterotomy
The anal sphincter mechanism comprises internal and external sphincters. The spasm of the internal sphincter that occurs because of an anal fissure is relieved by the procedure of lateral sphincterotomy, allowing the fissure to heal in about 2 weeks. The procedure gives dramatic relief; however, the complication of permanent faecal incontinence has to be considered and surgical intervention with excision of the fissure is usually preferred practice.1