Treatment

• Ensure stools are soft and easy to pass.
  • If the anal fissure is caused by constipation, manage symptoms of constipation with changes to diet and lifestyle.^2-4
  • If the anal fissure is not caused by constipation, ensure adequate dietary fibre intake by recommending a balanced diet containing whole grains, fruits, and vegetables.²
  • Advise on adequate hydration; adequate fluid intake is particularly important with an increased fibre diet.²

• Manage pain.²
  • Simple analgesia can be used (paracetamol or ibuprofen) if there is prolonged burning pain following defaecation. Opioid analgesics should be avoided as they can cause constipation and exacerbate symptoms.
  • Sitting in a shallow, warm bath several times a day may help (particularly after a bowel movement).
  • For an adult with extreme pain on defaecation, a short course of a topical anaesthetic (lidocaine 5% ointment) for use before passing a stool may be considered.
  • For an adult who presents with chronic anal fissure, topical rectal glyceryl trinitrate (GTN) 0.4% ointment may be considered.

• Follow lifestyle advice to aid healing of the anal fissure.²
  • The anal region should be kept clean and dry to aid healing and avoid complications of anal fissure (such as infection or abscess).
  • ‘Stool withholding' and undue straining during bowel movements should be avoided as they can worsen anal fissure.

Following initial management, if the anal fissure is unhealed in an adult after 6-8 weeks but the patient is asymptomatic or has notable symptomatic improvement, they may be referred to secondary care.⁵

Please note:

Further assessment using a suspected cancer pathway should be considered in the following groups.

• In adults aged under 50 years presenting rectal bleeding with abdominal pain or change in bowel habit or weight loss or iron deficiency anaemia.⁶
• In patients aged 50 and over reporting unexplained rectal bleeding.⁶