Anal Fissure

  • Kim C. LuEmail author
  • Daniel O. Herzig


An anal fissure is a tear in the anoderm, typically in the posterior midline. In the first 6 weeks, they will likely resolve with increased fiber and water, laxatives, and topical lidocaine. Chronic anal fissures, however, heal only 35.5 % of the time without further management. Nearly all treatments seek to relax the hypertonic internal anal sphincter. Perianal topical nitroglycerin, perianal topical diltiazem, and intramuscular (internal anal sphincter) injection of botulinum toxin are slightly more effective than placebo in healing anal fissures. Lateral internal anal sphincterotomy is far more effective (>90 %) in healing anal fissure. There is no difference between closed vs. open sphincterotomy techniques. Atypical anal fissures may require biopsy to rule out infectious disease, inflammatory bowel disease, or malignancy. For patients with hypotonic anal sphincters, dermal advancement flap to close the anal fissure should be considered. This chapter will cover the diagnosis, medical, and surgical management of anal fissures.


Acute anal fissure Chronic anal fissure Topical nitroglycerin or calcium channel blockers Botulinum toxin injection Lateral internal anal sphincterotomy Dermal advancement flap 

Supplementary material

Video 13.1

Anoplasty for anal stenosis. Courtesy of ASCRS (MP4 100,338 kb)


  1. 1.
    Herzig DO, Lu KC. Anal fissure. Surg Clin North Am. 2010;90:33–44.CrossRefGoogle Scholar
  2. 2.
    Ricciardi R, Dykes S, Madoff R. Anal fissure. In: Beck DE, Roberts P, Saclarides TK, Senagore AJ, Stamos MJ, Wexner SD, editors. The ASCRS textbook of colon and rectal surgery. 2nd ed. New York, NY: Springer; 2011. p. 203–18.CrossRefGoogle Scholar
  3. 3.
    Hoexter B. Anal fissure. In: Fazio VW, Church J, Delaney CP, editors. Current therapy in colon and rectal surgery. 2nd ed. Philadelphia, PA: Elsevier Mosby; 2005. p. 19–22.CrossRefGoogle Scholar
  4. 4.
    Perry GG. Fissure in ano--a complication of anusitis. South Med J. 1962;55:955–7.CrossRefGoogle Scholar
  5. 5.
    Farouk R, Duthie GS, MacGregor AB, Bartolo DC. Sustained internal sphincter hypertonia in patients with chronic anal fissure. Dis Colon Rectum. 1994;37:424–9.CrossRefGoogle Scholar
  6. 6.
    Nothmann BJ, Schuster MM. Internal anal sphincter derangement with anal fissures. Gastroenterology. 1974;67:216–20.PubMedGoogle Scholar
  7. 7.
    Gibbons CP, Read NW. Anal hypertonia in fissures: cause or effect? Br J Surg. 1986;73:443–5.CrossRefGoogle Scholar
  8. 8.
    Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum. 1989;32:43–52.CrossRefGoogle Scholar
  9. 9.
    Schouten WR, Briel JW, Auwerda JJ, De Graaf EJ. Ischaemic nature of anal fissure. Br J Surg. 1996;83:63–5.CrossRefGoogle Scholar
  10. 10.
    Perry WB, Dykes SL, Buie WD, Rafferty JF. Standards Practice Task Force of the American Society of C, Rectal S. Practice parameters for the management of anal fissures (3rd revision). Dis Colon Rectum. 2010;53:1110–5.CrossRefGoogle Scholar
  11. 11.
    Jensen SL. Treatment of first episodes of acute anal fissure: prospective randomised study of lignocaine ointment versus hydrocortisone ointment or warm sitz baths plus bran. Br Med J. 1986;292:1167–9.CrossRefGoogle Scholar
  12. 12.
    Nelson RL, Thomas K, Morgan J, Jones A. Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012; (2): CD003431.Google Scholar
  13. 13.
    O’Kelly T, Brading A, Mortensen N. Nerve mediated relaxation of the human internal anal sphincter: the role of nitric oxide. Gut. 1993;34:689–93.CrossRefGoogle Scholar
  14. 14.
    Loder PB, Kamm MA, Nicholls RJ, Phillips RK. ‘Reversible chemical sphincterotomy’ by local application of glyceryl trinitrate. Br J Surg. 1994;81:1386–9.CrossRefGoogle Scholar
  15. 15.
    Lund JN, Scholefield JH. A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure. Lancet. 1997;349:11–4.CrossRefGoogle Scholar
  16. 16.
    Jonas M, Barrett DA, Shaw PN, Scholefield JH. Systemic levels of glyceryl trinitrate following topical application to the anoderm do not correlate with the measured reduction in anal pressure. Br J Surg. 2001;88:1613–6.CrossRefGoogle Scholar
  17. 17.
    Brisinda G, Maria G, Bentivoglio AR, Cassetta E, Gui D, Albanese A. A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. N Engl J Med. 1999;341:65–9.CrossRefGoogle Scholar
  18. 18.
    Lund JN, Armitage NC, Scholefield JH. Use of glyceryl trinitrate ointment in the treatment of anal fissure. Br J Surg. 1996;83:776–7.CrossRefGoogle Scholar
  19. 19.
    Watson SJ, Kamm MA, Nicholls RJ, Phillips RK. Topical glyceryl trinitrate in the treatment of chronic anal fissure. Br J Surg. 1996;83:771–5.CrossRefGoogle Scholar
  20. 20.
    Perez-Legaz J, Arroyo A, Moya P, Ruiz-Tovar J, Frangi A, Candela F, et al. Perianal versus endoanal application of glyceryl trinitrate 0.4% ointment in the treatment of chronic anal fissure: results of a randomized controlled trial. Is this the solution to the headaches? Dis Colon Rectum. 2012;55:893–9.CrossRefGoogle Scholar
  21. 21.
    Chrysos E, Xynos E, Tzovaras G, Zoras OJ, Tsiaoussis J, Vassilakis SJ. Effect of nifedipine on rectoanal motility. Dis Colon Rectum. 1996;39:212–6.CrossRefGoogle Scholar
  22. 22.
    Carapeti EA, Kamm MA, Phillips RK. Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects. Dis Colon Rectum. 2000;43:1359–62.CrossRefGoogle Scholar
  23. 23.
    Jonas M, Neal KR, Abercrombie JF, Scholefield JH. A randomized trial of oral vs. topical diltiazem for chronic anal fissures. Dis Colon Rectum. 2001;44:1074–8.CrossRefGoogle Scholar
  24. 24.
    Bielecki K, Kolodziejczak M. A prospective randomized trial of diltiazem and glyceryltrinitrate ointment in the treatment of chronic anal fissure. Colorectal Dis. 2003;5:256–7.CrossRefGoogle Scholar
  25. 25.
    Kocher HM, Steward M, Leather AJ, Cullen PT. Randomized clinical trial assessing the side-effects of glyceryl trinitrate and diltiazem hydrochloride in the treatment of chronic anal fissure. Br J Surg. 2002;89:413–7.CrossRefGoogle Scholar
  26. 26.
    Cheng CM, Chen JS, Patel RP. Unlabeled uses of botulinum toxins: a review, part 1. Am J Health Syst Pharm. 2006;63:145–52.CrossRefGoogle Scholar
  27. 27.
    Tjandra JJ. Ambulatory haemorrhoidectomy - has the time come? ANZ J Surg. 2005;75:183.CrossRefGoogle Scholar
  28. 28.
    Gui D, Cassetta E, Anastasio G, Bentivoglio AR, Maria G, Albanese A. Botulinum toxin for chronic anal fissure. Lancet. 1994;344:1127–8.CrossRefGoogle Scholar
  29. 29.
    Maria G, Brisinda G, Bentivoglio AR, Cassetta E, Gui D, Albanese A. Influence of botulinum toxin site of injections on healing rate in patients with chronic anal fissure. Am J Surg. 2000;179:46–50.CrossRefGoogle Scholar
  30. 30.
    Maria G, Cassetta E, Gui D, Brisinda G, Bentivoglio AR, Albanese A. A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med. 1998;338:217–20.CrossRefGoogle Scholar
  31. 31.
    Arroyo A, Perez F, Serrano P, Candela F, Lacueva J, Calpena R. Surgical versus chemical (botulinum toxin) sphincterotomy for chronic anal fissure: long-term results of a prospective randomized clinical and manometric study. Am J Surg. 2005;189:429–34.CrossRefGoogle Scholar
  32. 32.
    Iswariah H, Stephens J, Rieger N, Rodda D, Hewett P. Randomized prospective controlled trial of lateral internal sphincterotomy versus injection of botulinum toxin for the treatment of idiopathic fissure in ano. ANZ J Surg. 2005;75:553–5.CrossRefGoogle Scholar
  33. 33.
    Mentes BB, Irkorucu O, Akin M, Leventoglu S, Tatlicioglu E. Comparison of botulinum toxin injection and lateral internal sphincterotomy for the treatment of chronic anal fissure. Dis Colon Rectum. 2003;46:232–7.CrossRefGoogle Scholar
  34. 34.
    Chen HL, Woo XB, Wang HS, Lin YJ, Luo HX, Chen YH, et al. Botulinum toxin injection versus lateral internal sphincterotomy for chronic anal fissure: a meta-analysis of randomized control trials. Tech Coloproctol. 2014;18:693–8.CrossRefGoogle Scholar
  35. 35.
    Gandomkar H, Zeinoddini A, Heidari R, Amoli HA. Partial lateral internal sphincterotomy versus combined botulinum toxin A injection and topical diltiazem in the treatment of chronic anal fissure: a randomized clinical trial. Dis Colon Rectum. 2015;58:228–34.CrossRefGoogle Scholar
  36. 36.
    Saad AM, Omer A. Surgical treatment of chronic fissure-in-ano: a prospective randomised study. East Afr Med J. 1992;69:613–5.PubMedGoogle Scholar
  37. 37.
    Steele SR, Madoff RD. Systematic review: the treatment of anal fissure. Aliment Pharmacol Ther. 2006;24:247–57.CrossRefGoogle Scholar
  38. 38.
    Nelson RL, Chattopadhyay A, Brooks W, Platt I, Paavana T, Earl S. Operative procedures for fissure in ano. Cochrane Database Syst Rev. 2011; (11): CD002199.Google Scholar
  39. 39.
    Renzi A, Izzo D, Di Sarno G, Talento P, Torelli F, Izzo G, et al. Clinical, manometric, and ultrasonographic results of pneumatic balloon dilatation vs. lateral internal sphincterotomy for chronic anal fissure: a prospective, randomized, controlled trial. Dis Colon Rectum. 2008;51:121–7.CrossRefGoogle Scholar
  40. 40.
    Eisenhammer S. The evaluation of the internal anal sphincterotomy operation with special reference to anal fissure. Surg Gynecol Obstet. 1959;109:583–90.PubMedGoogle Scholar
  41. 41.
    Notaras MJ. Lateral subcutaneous sphincterotomy for anal fissure--a new technique. Proc R Soc Med. 1969;62:713.PubMedPubMedCentralGoogle Scholar
  42. 42.
    Arroyo A, Perez F, Serrano P, Candela F, Calpena R. Open versus closed lateral sphincterotomy performed as an outpatient procedure under local anesthesia for chronic anal fissure: prospective randomized study of clinical and manometric longterm results. J Am Coll Surg. 2004;199:361–7.CrossRefGoogle Scholar
  43. 43.
    Filingeri V, Gravante G. A prospective randomized trial between subcutaneous lateral internal sphincterotomy with radiofrequency bistoury and conventional parks’ operation in the treatment of anal fissures. Eur Rev Med Pharmacol Sci. 2005;9:175–8.PubMedGoogle Scholar
  44. 44.
    Boulos PB, Araujo JG. Adequate internal sphincterotomy for chronic anal fissure: subcutaneous or open technique? Br J Surg. 1984;71:360–2.CrossRefGoogle Scholar
  45. 45.
    Kortbeek JB, Langevin JM, Khoo RE, Heine JA. Chronic fissure-in-ano: a randomized study comparing open and subcutaneous lateral internal sphincterotomy. Dis Colon Rectum. 1992;35:835–7.CrossRefGoogle Scholar
  46. 46.
    Wiley M, Day P, Rieger N, Stephens J, Moore J. Open vs. closed lateral internal sphincterotomy for idiopathic fissure-in-ano: a prospective, randomized, controlled trial. Dis Colon Rectum. 2004;47:847–52.CrossRefGoogle Scholar
  47. 47.
    Garcia-Granero E, Sanahuja A, Garcia-Botello SA, Faiz O, Esclapez P, Espi A, et al. The ideal lateral internal sphincterotomy: clinical and endosonographic evaluation following open and closed internal anal sphincterotomy. Colorectal Dis. 2009;11:502–7.CrossRefGoogle Scholar
  48. 48.
    Mentes BB, Ege B, Leventoglu S, Oguz M, Karadag A. Extent of lateral internal sphincterotomy: up to the dentate line or up to the fissure apex? Dis Colon Rectum. 2005;48:365–70.CrossRefGoogle Scholar
  49. 49.
    Elsebae MM. A study of fecal incontinence in patients with chronic anal fissure: prospective, randomized, controlled trial of the extent of internal anal sphincter division during lateral sphincterotomy. World J Surg. 2007;31:2052–7.CrossRefGoogle Scholar
  50. 50.
    Magdy A, El Nakeeb A, el Fouda Y, Youssef M, Farid M. Comparative study of conventional lateral internal sphincterotomy, V-Y anoplasty, and tailored lateral internal sphincterotomy with V-Y anoplasty in the treatment of chronic anal fissure. J Gastrointest Surg. 2012;16:1955–62.CrossRefGoogle Scholar
  51. 51.
    Mentes BB, Guner MK, Leventoglu S, Akyurek N. Fine-tuning of the extent of lateral internal sphincterotomy: spasm-controlled vs. up to the fissure apex. Dis Colon Rectum. 2008;51:128–33.CrossRefGoogle Scholar
  52. 52.
    Pelta AE, Davis KG, Armstrong DN. Subcutaneous fissurotomy: a novel procedure for chronic fissure-in-ano. a review of 109 cases. Dis Colon Rectum. 2007;50:1662–7.CrossRefGoogle Scholar
  53. 53.
    Garcia-Aguilar J, Belmonte C, Wong WD, Lowry AC, Madoff RD. Open vs. closed sphincterotomy for chronic anal fissure: long-term results. Dis Colon Rectum. 1996;39:440–3.CrossRefGoogle Scholar
  54. 54.
    Madoff RD, Fleshman JW. AGA technical review on the diagnosis and care of patients with anal fissure. Gastroenterology. 2003;124:235–45.CrossRefGoogle Scholar
  55. 55.
    Floyd ND, Kondylis L, Kondylis PD, Reilly JC. Chronic anal fissure: 1994 and a decade later--are we doing better? Am J Surg. 2006;191:344–8.CrossRefGoogle Scholar
  56. 56.
    Lysy J, Israeli E, Levy S, Rozentzweig G, Strauss-Liviatan N, Goldin E. Long-term results of “chemical sphincterotomy” for chronic anal fissure: a prospective study. Dis Colon Rectum. 2006;49:858–64.CrossRefGoogle Scholar
  57. 57.
    Giordano P, Gravante G, Grondona P, Ruggiero B, Porrett T, Lunniss PJ. Simple cutaneous advancement flap anoplasty for resistant chronic anal fissure: a prospective study. World J Surg. 2009;33:1058–63.CrossRefGoogle Scholar
  58. 58.
    Nyam DC, Wilson RG, Stewart KJ, Farouk R, Bartolo DC. Island advancement flaps in the management of anal fissures. Br J Surg. 1995;82:326–8.CrossRefGoogle Scholar
  59. 59.
    Kenefick NJ, Gee AS, Durdey P. Treatment of resistant anal fissure with advancement anoplasty. Colorectal Dis. 2002;4:463–6.CrossRefGoogle Scholar
  60. 60.
    Sangwan YP, Schoetz Jr DJ, Murray JJ, Roberts PL, Coller JA. Perianal Crohn’s disease. Results of local surgical treatment. Dis Colon Rectum. 1996;39:529–35.CrossRefGoogle Scholar
  61. 61.
    Platell C, Mackay J, Collopy B, Fink R, Ryan P, Woods R. Anal pathology in patients with Crohn’s disease. ANZ J Surg. 1996;66:5–9.CrossRefGoogle Scholar
  62. 62.
    Wolkomir AF, Luchtefeld MA. Surgery for symptomatic hemorrhoids and anal fissures in Crohn’s disease. Dis Colon Rectum. 1993;36:545–7.CrossRefGoogle Scholar
  63. 63.
    Fleshner PR, Schoetz Jr DJ, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC. Anal fissure in Crohn’s disease: a plea for aggressive management. Dis Colon Rectum. 1995;38:1137–43.CrossRefGoogle Scholar
  64. 64.
    Ouraghi A, Nieuviarts S, Mougenel JL, Allez M, Barthet M, Carbonnel F, et al. Infliximab therapy for Crohn’s disease anoperineal lesions. Gastroenterol Clin Biol. 2001;25:949–56.PubMedGoogle Scholar
  65. 65.
    Sweeney JL, Ritchie JK, Nicholls RJ. Anal fissure in Crohn’s disease. Br J Surg. 1988;75:56–7.CrossRefGoogle Scholar
  66. 66.
    Viamonte M, Dailey TH, Gottesman L. Ulcerative disease of the anorectum in the HIV+ patient. Dis Colon Rectum. 1993;36:801–5.CrossRefGoogle Scholar
  67. 67.
    Weiss EG, Wexner SD. Surgery for anal lesions in HIV-infected patients. Ann Med. 1995;27:467–75.CrossRefGoogle Scholar

Copyright information

© ASCRS (American Society of Colon and Rectal Surgeons) 2016

Open Access This chapter is licensed under the terms of the Creative Commons Attribution-NonCommercial 2.5 International License (, which permits any noncommercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

Authors and Affiliations

  1. 1.Division of Gastrointestinal and General Surgery, Department of SurgeryOregon Health & Science UniversityPortlandUSA

Personalised recommendations