Anal Fissure and Fistula

Anal Fissure and Anal Fistula – Treatment Overview

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Anal Fissure

Introduction
An anal fissure is a tear in the lining of the anal canal, usually caused by trauma from hard stools, constipation, or prolonged diarrhea. It presents with severe anal pain during or after defecation and bright red bleeding on toilet paper.

Treatment

• Conservative measures (first-line): High-fiber diet, stool softeners, hydration, warm sitz baths (10–15 minutes several times daily), and topical analgesics such as lidocaine gel.

• Medical therapy: Topical nitroglycerin 0.2–0.4% ointment applied twice daily, or topical calcium channel blockers (diltiazem 2% or nifedipine 0.2–0.3% ointment) applied twice daily. These relax the internal anal sphincter and promote healing. Botulinum toxin injection (20–40 units into the internal sphincter) can also be used if topical therapy fails.

• Surgical therapy: For chronic or refractory fissures, lateral internal sphincterotomy (LIS) is considered the gold standard, achieving over 90% healing rates but with some risk of incontinence.

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Anal Fistula

Introduction
An anal fistula is an abnormal tract connecting the anal canal to the perianal skin, usually developing after perianal abscess drainage. Symptoms include recurrent perianal discharge, pain, and swelling.

Treatment

• Fistulas do not heal spontaneously; surgical management is always required. The choice depends on the tract’s complexity and sphincter involvement.

• Simple or low fistulas (minimal sphincter involvement): Fistulotomy (laying open the tract) is the preferred option and has a high success rate.

• Complex or high fistulas (involving more sphincter muscle): Sphincter-sparing techniques are used, such as seton placement (to allow drainage and fibrosis), advancement flap repair (covering the internal opening with rectal mucosa), or the LIFT procedure (ligation of intersphincteric fistula tract). Fibrin glue or fistula plugs are also options but generally less effective.