CLINICAL PRACTICE GUIDELINES Clinical Practice Guideline for the Management of Anal Fissures David B. Stewart, Sr., M.D. • Wolfgang Gaertner, M.D. • Sean Glasgow, M.D. John Migaly, M.D. • Daniel Feingold, M.D. • Scott R. Steele, M.D. Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons he American Society of Colon and Rectal Surgeons anal fissures is anal pain, which is often provoked by def- is dedicated to ensuring high-quality patient care ecation and may last for several hours following defecation. Tby advancing the science, prevention, and manage- Anorectal bleeding may also be associated with fissures, ment of disorders and diseases of the colon, rectum, and and, when this symptom is present, it can contribute to a anus. The Clinical Practice Guidelines Committee is com- misdiagnosis of symptomatic hemorrhoids. In up to 90% of posed of society members who are chosen because they cases, the anal fissure is located within the posterior midline have demonstrated expertise in the specialty of colon and of the anal canal. Fissures are located in the anterior midline rectal surgery. This committee was created to lead interna- in as many as 25% of female patients and in as many as 8% tional efforts in defining quality care for conditions related of male subjects. In 3% of patients, fissures can be located to the colon, rectum, and anus. This is accompanied by at posterior and anterior positions simultaneously. Fissures developing clinical practice guidelines based on the best located at lateral locations within the anal canal, and multi- available evidence. These guidelines are inclusive, and not ple fissures, are considered to be atypical and require careful prescriptive. Their purpose is to provide information based evaluation because of their association with such diseases on which decisions can be made, rather than to dictate a as HIV infection, Crohn’s disease, syphilis, tuberculosis, and specific form of treatment. These guidelines are intended hematologic malignancies. for the use of all practitioners, health care workers, and Acute fissures, defined as symptoms present for fewer patients who desire information about the management than 8 weeks, will appear as a longitudinal tear. Fissures of of the conditions addressed by the topics covered in these a longer duration will manifest one or more stigmata of guidelines. It should be recognized that these guidelines chronicity, including a hypertrophied anal papilla at the should not be deemed inclusive of all proper methods of proximal aspect of the fissure, a sentinel tag at the distal care or exclusive of methods of care reasonably directed aspect of the fissure, and exposed internal anal sphincter toward obtaining the same results. The ultimate judgment muscle within the base of the fissure. regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances pre- sented by the individual patient. METHODOLOGY These guidelines were built on the last set of the American STATEMENT OF THE PROBLEM Society of Colon and Rectal Surgeons practice parameters for treatment of fissure-in-ano published in 2004.A n orga- The term anal fissure most commonly refers to a longitudi- nized search of MEDLINE, PubMed, EMBASE, and the Co- nal tear within the anal canal, one that typically extends from chrane Database of Collected Reviews was performed from the dentate line toward the anal verge. This benign anorectal October 2015 through March 2016. Retrieved publications ailment is quite common, although there have been virtu- were limited to the English language, but no limits on year ally no published1 population-level data describing its inci- of publication were applied. The search strategies were dence. Constipation and diarrhea are frequent antecedent based on the concepts “anal fissure” and “fissure-in-ano” as historical features. The primary symptom associated with primary search terms. Searches were also performed based on various treatments for anal fissures, including “anal fis- Financial Disclosures: None reported. sure AND nitroglycerin,” “anal fissureAN D nitrates,” “anal Dis Colon Rectum 2017; 60: 7–14 fissureAN D diltiazem,” “anal fissureAN D nifedipine,” “anal DOI: 10.1097/DCR.0000000000000735 fissureAN D fiber,” “anal fissureAN D botulinum,” “anal fis- © The ASCRS 2016 sure AND sphincterotomy,” and “anal fissureAN D flap.” DISEASES OF THE COLON & RECTUM VOLUME 60: 1 (2017) 7 Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited. 8 STEWART ET AL: CLINICAL PRACTICE GUIDELINE FOR ANAL FISSURE MANAGEMENT Directed searches of the embedded references from the pri- recurrence compared with placebo.6 There are no data sup- mary articles were also performed in certain circumstances. porting one type of fiber in comparison with another. Prospective, randomized, controlled trials and meta-anal- 2. Anal fissures may be treated with topical nitrates, al- yses were given preference in developing these guidelines. though side effects may limit their efficacy. Grade of The final grade of recommendation was performed using Recommendation: Strong recommendation based on the Grades of Recommendation, Assessment, Develop- high-quality evidence, 1A. ment, and Evaluation (GRADE) system (Table 1).2 Topical nitric oxide donors are associated with healing in approximately 50% of chronic anal fissures.8 Based RECOMMENDATIONS on a pooled analysis of studies, this represents a 13.5% 1. Nonoperative treatment of acute anal fissures contin- improvement in the absolute rate of healing and a 38% ues to be safe, has few side effects, and should typically relative improvement in the rate of healing compared be the first-line treatment. Grade of Recommendation: with placebo or lidocaine alone.9 Dose escalation does not Strong recommendation based on moderate-quality improve healing rates, but escalating doses are associated evidence, 1B. with an increased incidence of medication side effects.10,11 Almost half of all patients who have acute anal fissure will The principal side effect with this medication is head- resolve their symptoms with nonoperative measures such aches, occurring in at least 30% of treated patients and as sitz baths and the use of psyllium fiber or other bulking being nearly ubiquitous in some reports.8,12 This adverse agents, with or without the addition of topical anesthetics effect is dose related and leads to the cessation of therapy or topical steroids.1,3–7 These interventions are well toler- in up to 20% of patients.13 In addition, up to 50% of pa- ated, with minimal to no side effects. Treatment with sitz tients treated with this medication experience recurrent baths and fiber supplementation is associated with a superi- fissures, a significantly higher percentage than observed or degree of pain relief in comparison with topical anesthet- with surgical treatment.9 Nonresponders to topical ni- ics and topical hydrocortisone.3 In addition, maintenance trates should, in general, be considered either for botuli- therapy with fiber is associated with lower rates of fissure num toxin therapy or for a surgical sphincterotomy. TABLE 1. The GRADE system grading recommendations Methodological quality Implications Description Benefit vs risk and burdens of supporting evidence 1A Strong recommendation, Benefits clearly outweigh RCTs without important limitations Strong recommendation, can apply to High-quality evidence risk and burdens or vice or overwhelming evidence from most patients in most circumstances versa observational studies without reservation 1B Strong recommendation, Benefits clearly outweigh RCTs with important limitations Strong recommendation, can apply to Moderate-quality risk and burdens or vice (inconsistent results, most patients in most circumstances evidence versa methodological flaws, indirect, without reservation or imprecise) or exceptionally strong evidence from observational studies 1C Strong recommendation, Benefits clearly outweigh Observational studies or case series Strong recommendation but may Low- or very-low- risk and burdens or vice change when higher-quality evidence quality evidence versa becomes available 2A Weak recommendation, Benefits closely balanced RCTs without important limitations Weak recommendation, best action may High-quality evidence with risks and burdens or overwhelming evidence from differ depending on circumstances or observational studies patients’ or societal values 2B Weak recommendations, Benefits closely balanced RCTs with important limitations Weak recommendation, best action may Moderate-quality with risks and burdens (inconsistent results, differ depending on circumstances or evidence methodological flaws, indirect, patients’ or societal values or imprecise) or exceptionally strong evidence from observational studies 2C Weak recommendation, Uncertainty in the Observational studies or case series Very weak recommendations; other Low- or very-low- estimates of benefits, alternatives may be equally quality evidence risks, and burden; reasonable benefits, risks, and burden may be closely balanced GRADE = Grades of Recommendation, Assessment, Development, and Evaluation; RCT = randomized controlled trial. Adapted from Guyatt G, Gutermen D, Baumann MH, et al. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians Task Force. Chest. 2006;129:174–181.2 Used with permission.