This is the current release of the guideline.

This guideline updates a previous version: American Society of Colon and Rectal Surgeons. Practice parameters for the management of anal fissure. Arlington Heights (IL): American Society of Colon and Rectal Surgeons; 1998-1999. 4 p.

The levels of evidence (classes I-V) and the grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.

Treatment Recommendations

1. Conservative therapy is safe, has few side effects, and should usually be the first step in therapy. Level of evidence: Class II; Grade of recommendation: B.
2. Anal fissures may be appropriately treated with topical nitrates because they can relieve pain; however, nitrates are only marginally associated with a healing rate superior to placebo. Level of evidence: Class I; Grade of recommendation: A.
3. Anal fissures may be appropriately treated with topical calcium channel blockers, which seem to have a lower incidence of adverse effects than nitrates. There is insufficient data to conclude whether they are superior to placebo in healing fissures. Level of evidence: Class I; Grade of recommendation: A.
4. Botulinum toxin injections may be used for anal fissures that fail to respond to conservative measures and have been associated with a healing rate superior to placebo. There is inadequate consensus on dosage, precise site of administration, number of injections, or efficacy. Level of evidence: Class II; Grade of recommendation: B.
5. Lateral internal sphincterotomy (LIS) is the surgical treatment of choice for refractory anal fissures. Level of evidence: Class I; Grade of recommendation: A.
6. Open and closed techniques for LIS seem to yield similar results. Level of evidence: Class I; Grade of recommendation: A.
7. Anal advancement flap is an alternative to LIS; further study is required. Level of evidence: Class II; Grade of recommendation: D.
8. Surgery may be appropriately offered without a trial of pharmacologic treatment after failure of conservative therapy; patient should be informed about the potential complications of surgery. Level of evidence: Class I; Grade of recommendation: A.

Definitions:

Levels of Evidence (Class)

1. Meta-analysis of multiple well-designed, controlled studies; randomized trials with low false-positive and low false-negative errors (high power)
2. At least one well-designed experimental study; randomized trials with high false-positive or high false-negative errors or both (low power)
3. Well-designed, quasi-experimental studies, such as nonrandomized, controlled, single-group, preoperative-postoperative comparison, cohort, time, or matched case-control series
4. Well-designed, nonexperimental studies, such as comparative and correlational descriptive and case studies
5. Case reports and clinical examples

Grades of Recommendations

1. Evidence of Type I or consistent findings from multiple studies of Type II, III, or IV
2. Evidence of Type II, III, or IV and generally consistent findings
3. Evidence of Type II, III, or IV but inconsistent findings
4. Little or no systematic empirical evidence

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations" field).

Not applicable: Guideline was not adapted from another source.

1992 (revised 2004 Dec)

American Society of Colon and Rectal Surgeons - Medical Specialty Society

Not stated

Standards Task Force of the American Society of Colon and Rectal Surgeons

Task Force Members: Charles Orsay, MD; Jan Rakinic, MD; W. Brian Perry, MD; Neil Hyman, MD; Donald Buie, MD; Peter Cataldo, MD; Graham Newstead, MD; Gary Dunn, MD; Janice Rafferty, MD; C. Neal Ellis, MD; Paul Shellito, MD; Sharon Gregorcyk, MD; Charles Ternent, MD; John Kilkenny III, MD; Joe Tjandra, MD; Clifford Ko, MD; Mark Whiteford, MD; Richard Nelson, MD

Not stated

This is the current release of the guideline.

This guideline updates a previous version: American Society of Colon and Rectal Surgeons. Practice parameters for the management of anal fissure. Arlington Heights (IL): American Society of Colon and Rectal Surgeons; 1998-1999. 4 p.

None available

None available

This summary was completed by ECRI on February 15, 2000. The information was verified by the guideline developer as November 7, 2000. This NGC summary was updated by ECRI on March 3, 2005.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.