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Anal Fissure

NICE CKS Anal Fissure. Last revised: Apr 2021. NICE BNF Treatment summaries. Anal fissure.

Guidelines

Offer FITFaecal immunochemical testing to those with any of the following red flags:

With an abdominal mass
With a change in bowel habit
With iron-deficiency anaemia
≥40 y/o with unexplained weight loss and abdominal pain
<50 y/o with rectal bleeding and either of the following unexplained symptoms:
- Abdominal pain
- Weight loss
≥50 y/o with any of the following unexplained symptoms:
- Rectal bleeding
- Abdominal pain
- Weight loss
≥60 y/o with anaemia even in the absence of iron deficiency

If is +ve → refer with suspected cancer pathway

Approach:

Step 1 (all patients): conservative / general management + analgesia
Step 2 (if no improvement after 1 week): add on topical therapy
Step 3 (if all pharmacological therapy failed): add on surgery

Advise the following to ALL patients:

Ensure stools are soft and easy to pass
- Advise adequate dietary fibre intake
- 1st line: bulk-forming laxatives (e.g. ispaghula husk)
- 2nd line: osmotic laxative (lactulose)

Anal hygiene
- Keep the anal region clean and dry to aid healing
- Advise against 'stool withholding' and undue straining during bowel movements

Offer analgesia:

Paracetamol or ibuprofen if there is prolonged burning pain following defecation
Avoid opioids as they can cause constipation
Sitting in a shallow, warm bath several times a day, esp. after a bowel movement may help
Consider a short course of topical lidocaine ointment to be used before passing stool in those with extreme pain

If symptoms do not improve after 1 week, consider:

Step 1: rectal GTNGlyceryl trinitrate ointment for 6-8 weeks
Step 2 (if no improvement): seek specialist advice on alternatives like topical diltiazem
Step 3 (if no improvement): consider botulinum toxin type A injection

To be used as a last resort: lateral internal sphincterotomy

Most effective surgical surgery - 90-95% healing rates
However, there is risk of some degree of faecal incontinence

References

NICE CKS Anal fissure
NICE BNF Treatment summaries Anal fissure

Author: Adams Lau
Reviewer:
Last edited: 10/08/25

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