Management of Anal Fissures

Publication Date: January 31, 2023

Summary of Recommendations

Nonoperative treatment of acute anal fissures is safe and should typically be first-line treatment. (1B)

Anal fissures may be treated with topical nitrates, although headache symptoms may limit their efficacy. (1B)

Compared with topical nitrates, the use of calcium channel blockers for chronic anal fissures has similar efficacy, with a superior side-effect profile, and can be used as first-line treatment. (1B)

Botulinum toxin has similar results compared with topical therapies as first-line therapy for chronic anal fissures and modest improvement in healing rates as second-line therapy following failed treatment with topical therapies. (1B)

Lateral internal sphincterotomy may be offered in selected pharmacologically naive patients with chronic anal fissure. (1A)

LIS is the treatment of choice for chronic anal fissures in selected patients without baseline FI. (1A)

Open and closed techniques of LIS yield similar results and either technique may be used. (1A)

LIS tailored to the length of the fissure yields similar healing rates but decreased FI rates compared with traditional LIS extending to the dentate line. (1B)

Short-term outcomes of repeat LIS or botulinum injection for recurrent anal fissure have shown good healing rates with a low risk of FI, but the data are limited and require further study. (2C)

Anocutaneous flap is a safe surgical alternative for managing chronic anal fissure with a decreased risk of FI compared with LIS and comparable healing rates. (2B)

The addition of an anocutaneous flap to botulinum toxin injection or to LIS may decrease postoperative pain and allow for primary wound healing. (2C)

Recommendation Grading




Management of Anal Fissures

Authoring Organization

Publication Month/Year

January 31, 2023

Supplemental Implementation Tools

Document Type


Country of Publication


Target Patient Population

Adult patients with anal fissures

Target Provider Population

All practitioners, health care workers, and patients

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant



Diseases/Conditions (MeSH)

D005401 - Fissure in Ano


anal fissures, fissure-in-ano

Source Citation

Davids JS, Hawkins AT, Bhama AR, Feinberg AE, Grieco MJ, Lightner AL, Feingold DL, Paquette IM; Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures. Dis Colon Rectum. 2023 Feb 1;66(2):190-199. doi: 10.1097/DCR.0000000000002664. Epub 2022 Nov 1. PMID: 36321851.


Number of Source Documents
Literature Search Start Date
October 1, 2014
Literature Search End Date
March 20, 2022