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.

Chronic anal fissures

Management
Treatment

Colon and Rectal Surgery
Family Practice
Internal Medicine

Advanced Practice Nurses
Health Plans
Managed Care Organizations
Patients
Physician Assistants
Physicians

• To provide information about the management of chronic anal fissures to all practitioners, health care workers, and patients based on the best available evidence
• To outline principles that should provide a rational basis for objective evaluations of patients by physicians and third-party payors

Patients with chronic anal fissures

Conservative Therapy

1. Increased fiber and fluid ingestion
2. Sitz baths
3. Stool softeners (docusate sodium or docusate calcium)
4. Topical anesthetics

Pharmaceutical Therapy

1. Topical nitroglycerin (nitric oxide)
2. Topical calcium channel blockers
3. Oral calcium channel blockers (not recommended)
4. Botulinum toxin injections

Surgical Techniques

1. Lateral internal sphincterotomy (LIS) (recommended surgical management)
2. Anal advancement flap (alternative to LIS)
3. Fissurectomy (not recommended)
4. Anal dilation (not recommended)
5. Posterior midline sphincterotomy (not recommended)

• Rates of fissure recurrence
• Healing rates
• Incontinence rates
• Relief of symptoms from chronic anal fissures, such as bleeding and pain
• Safety and incidence of adverse effects of treatment

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The literature search was performed by searching Medline for "anal fissure" and "fissure" from 1980 to 2003. Evidence collected included data from published articles including controlled trials in refereed journals, textbooks, collective experience in practice, and opinions of the Standards Committee.

Exclusion

Articles that did not specify chronicity of the fissure were not included in the evaluation.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

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

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

Not stated

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

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

The guideline was reviewed by the Standards Task Force and the Executive Council of the American Society of Colon and Rectal Surgeons.

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).

Appropriate and effective treatment and management of chronic anal fissures

Topical treatments have problems with compliance, a lower rate of healing, and a higher recurrence rate than surgical treatment.

Treatment Specific Side Effects

• Topical nitroglycerin: headache
• Topical calcium channel blockers: headache, flushing, and less commonly symptomatic hypotension
• Botulinum toxin: transient incontinence of flatus and stool
• Lateral internal sphincterotomy (LIS): fecal incontinence
• Surgery: risk of minor fecal incontinence

• These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.
• The practice parameters have been developed from sources believed to be reliable. The American Society of Colon and Rectal Surgeons makes no warranty, guaranty, or representation whatsoever as to the absolute validity or sufficiency of any parameter, and the Society assumes no responsibility for the use or misuse of the material.

An implementation strategy was not provided.

Living with Illness

Effectiveness

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 summary was updated by ECRI Institute on March 10, 2009, following the U.S. Food and Drug Administration advisory on Topical Anesthetics. This summary was updated by ECRI Institute on May 26, 2009, following the U.S. Food and Drug Administration advisory on Botox, Botox Cosmetic (Botulinum toxin Type A), and Myobloc (Botulinum toxin Type B).

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