fissure in ano


Summary: A painful linear ulcer at the margin of the anus. It appears as a crack or slit in the mucous membrane of the anus and is very painful and difficult to heal. (Dorland, 27th ed & Stedman, 25th ed)

Top Publications

  1. Lund J, Nystrom P, Coremans G, Herold A, Karaitianos I, Spyrou M, et al. An evidence-based treatment algorithm for anal fissure. Tech Coloproctol. 2006;10:177-80 pubmed
    ..This algorithm may rationalize the treatment of anal fissure in primary and secondary care settings. ..
  2. Steele S, Madoff R. Systematic review: the treatment of anal fissure. Aliment Pharmacol Ther. 2006;24:247-57 pubmed
    ..Both non-operative and operative approaches currently exist for the management of anal fissure. Improved non-surgical therapies may continue to lessen the role of sphincter-dividing surgery in future. ..
  3. Nash G, Kapoor K, Saeb Parsy K, Kunanadam T, Dawson P. The long-term results of diltiazem treatment for anal fissure. Int J Clin Pract. 2006;60:1411-3 pubmed
    ..chemical sphincterotomy, patients should be aware that the majority of patients receiving diltiazem as the primary treatment for anal fissure subsequently require further treatment. ..
  4. Lewis R, Maron D. Anorectal Crohn's disease. Surg Clin North Am. 2010;90:83-97, Table of Contents pubmed publisher
    ..Complex fistulae can be closed with either an anal fistula plug or covered with flaps. Up to 20% of patients anorectal Crohn's disease require proctectomy for persistent and disabling disease. ..
  5. De Nardi P, Ortolano E, Radaelli G, Staudacher C. Comparison of glycerine trinitrate and botulinum toxin-a for the treatment of chronic anal fissure: long-term results. Dis Colon Rectum. 2006;49:427-32 pubmed
    ..None had fecal incontinence. Both treatments may be considered as first-line treatment even if less effective than surgery. ..
  6. Arroyo A, Perez F, Serrano P, Candela F, Calpena R. Long-term results of botulinum toxin for the treatment of chronic anal fissure: prospective clinical and manometric study. Int J Colorectal Dis. 2005;20:267-71 pubmed
    ..In patients with factors related to recurrence, re-injection with higher doses of botulinum toxin or complementary medical-surgical treatment should be considered. ..
  7. Bhardwaj R, Parker M. Modern perspectives in the treatment of chronic anal fissures. Ann R Coll Surg Engl. 2007;89:472-8 pubmed
    ..Sphincterotomy is indicated for unhealed fissures; fissurectomy has been revisited and advancement flaps have a role in patients in whom sphincter division is not suitable. ..
  8. Yucel T, Gonullu D, Oncu M, Koksoy F, Ozkan S, Aycan O. Comparison of controlled-intermittent anal dilatation and lateral internal sphincterotomy in the treatment of chronic anal fissures: a prospective, randomized study. Int J Surg. 2009;7:228-31 pubmed publisher
    ..In addition, the CIAD method may be an alternative procedure in older and multiparous women who has a higher risk of incontinence. ..
  9. Orsay C, Rakinic J, Perry W, Hyman N, Buie D, Cataldo P, et al. Practice parameters for the management of anal fissures (revised). Dis Colon Rectum. 2004;47:2003-7 pubmed

More Information


  1. Fruehauf H, Fried M, Wegmueller B, Bauerfeind P, Thumshirn M. Efficacy and safety of botulinum toxin a injection compared with topical nitroglycerin ointment for the treatment of chronic anal fissure: a prospective randomized study. Am J Gastroenterol. 2006;101:2107-12 pubmed
    ..Nitroglycerin ointment was superior to the more expensive and invasive botulinum toxin injection for initial healing of CAF, but was associated with more but mild side effects. ..
  2. Essani R, Sarkisyan G, Beart R, Ault G, Vukasin P, Kaiser A. Cost-saving effect of treatment algorithm for chronic anal fissure: a prospective analysis. J Gastrointest Surg. 2005;9:1237-43; discussion 1243-4 pubmed
    ..It is highly cost-efficient and resulted in savings of 41% (compared with BTX plus LIS) and up to 70% (compared with surgery in all patients), respectively. ..
  3. Renzi A, Brusciano L, Pescatori M, Izzo D, Napolitano V, Napoletano V, et al. Pneumatic balloon dilatation for chronic anal fissure: a prospective, clinical, endosonographic, and manometric study. Dis Colon Rectum. 2005;48:121-6 pubmed
    ..Pneumatic balloon dilation seems to be an effective, safe, easy procedure that decreases anal resting pressure without endosonographically detectable significant sphincter damage. ..
  4. Jones O, Ramalingam T, Lindsey I, Cunningham C, George B, Mortensen N. Digital rectal examination of sphincter pressures in chronic anal fissure is unreliable. Dis Colon Rectum. 2005;48:349-52 pubmed
    ..It is reasonable to treat all patients primarily medically, and then selectively investigate by manometry those patients who fail medical therapy before considering lateral sphincterotomy. ..
  5. Collins E, Lund J. A review of chronic anal fissure management. Tech Coloproctol. 2007;11:209-23 pubmed
    ..These and other non-surgical treatments are described in this review. Various guidelines and treatment algorithms for anal fissure are also discussed. ..
  6. Altomare D, Rinaldi M, Troilo V, Marino F, Lobascio P, Puglisi F. Closed ambulatory lateral internal sphincterotomy for chronic anal fissures. Tech Coloproctol. 2005;9:248-9 pubmed
  7. Lindsey I, Jones O, Cunningham C, Mortensen N. Chronic anal fissure. Br J Surg. 2004;91:270-9 pubmed
    ..If the initial good results of new sphincter-sparing surgery are confirmed, it may be possible to avoid any risk of incontinence, while achieving high rates of fissure healing. ..
  8. Griffin N, Acheson A, Tung P, Sheard C, Glazebrook C, Scholefield J. Quality of life in patients with chronic anal fissure. Colorectal Dis. 2004;6:39-44 pubmed
    ..05). Successful nonsurgical treatment of chronic anal fissure leads to symptomatic improvement and beneficially affects health-related quality of life. ..
  9. Kiyak G, Korukluoglu B, Kusdemir A, Sisman I, Ergul E. Results of lateral internal sphincterotomy with open technique for chronic anal fissure: evaluation of complications, symptom relief, and incontinence with long-term follow-up. Dig Dis Sci. 2009;54:2220-4 pubmed publisher
    ..Incontinence after LIS was only to flatus and two-thirds of these resolved in 6 weeks. No patient showed improvement of incontinence after 6 weeks. ..
  10. Sileri P, Stolfi V, Franceschilli L, Grande M, Di Giorgio A, D Ugo S, et al. Conservative and surgical treatment of chronic anal fissure: prospective longer term results. J Gastrointest Surg. 2010;14:773-80 pubmed publisher
    ..In conclusion, although LIS is far more effective than medical treatments, BTX injection/fissurectomy as first line treatment may significantly increase the healing rate while avoiding any risk of incontinence. ..
  11. Parellada C. Randomized, prospective trial comparing 0.2 percent isosorbide dinitrate ointment with sphincterotomy in treatment of chronic anal fissure: a two-year follow-up. Dis Colon Rectum. 2004;47:437-43 pubmed
    ..The aim of this trial was to compare lateral internal sphincterotomy with local 0.2 percent isosorbide dinitrate in the treatment of chronic anal fissure to minimize surgical complications such as minor fecal incontinence...
  12. Nelson R. A systematic review of medical therapy for anal fissure. Dis Colon Rectum. 2004;47:422-31 pubmed
    ..12; 0.07-0.22). Medical therapy for chronic anal fissure, acute fissure, and fissure in children may be applied with a chance of cure that is only marginally better than placebo, and for chronic fissure, far less effective than surgery. ..
  13. Fenton C, Wellington K, Easthope S. 0.4% nitroglycerin ointment : in the treatment of chronic anal fissure pain. Drugs. 2006;66:343-9 pubmed
    ..1 to >1 microg/L Volume of distribution approximate, equals 3 L/kg Clearance approximate, equals 1 L/kg/min Elimination half-life approximate, equals 3 min Most common adverse event Headache. ..
  14. Lund J. Nitric oxide deficiency in the internal anal sphincter of patients with chronic anal fissure. Int J Colorectal Dis. 2006;21:673-5 pubmed
    ..It may be that there is an abnormal failure of relaxation of internal sphincter in those patients who develop chronic anal fissure caused by an intrinsic lack of neural NOS in the internal anal sphincter. ..
  15. Gagliardi G, Pascariello A, Altomare D, Arcanà F, Cafaro D, La Torre F, et al. Optimal treatment duration of glyceryl trinitrate for chronic anal fissure: results of a prospective randomized multicenter trial. Tech Coloproctol. 2010;14:241-8 pubmed publisher
    ..Previous studies have reported that topical treatment of CAF with glyceryl trinitrate (GTN) reduces pain and promotes healing, but optimal treatment duration is unknown...
  16. Bove A, Balzano A, Perrotti P, Antropoli C, Lombardi G, Pucciani F. Different anal pressure profiles in patients with anal fissure. Tech Coloproctol. 2004;8:151-6; discussion 156-7 pubmed
    ..Patients with chronic anal fissures may have several anal pressure profiles. The anal canal is often normotonic. Fissures with hypertonic or normo-hypotonic anal canal need different therapies. ..
  17. Sands L. 0.4% nitroglycerin ointment in the treatment of chronic anal fissure pain : a viewpoint by Laurence R. Sands. Drugs. 2006;66:350-2 pubmed
  18. Herzig D, Lu K. Anal fissure. Surg Clin North Am. 2010;90:33-44, Table of Contents pubmed publisher
  19. Lindsey I, Jones O, Cunningham C, George B, Mortensen N. Botulinum toxin as second-line therapy for chronic anal fissure failing 0.2 percent glyceryl trinitrate. Dis Colon Rectum. 2003;46:361-6 pubmed
    ..Higher rates of healing may be achieved by giving botulinum toxin as first-line therapy, or addressing the chronic fibrotic nature of the fissure. ..
  20. Brisinda G, Maria G. Botulinum toxin in the treatment of chronic anal fissure. Dis Colon Rectum. 2003;46:1144-7; author reply 1147-8 pubmed
  21. Evans J, Luck A, Hewett P. Glyceryl trinitrate vs. lateral sphincterotomy for chronic anal fissure: prospective, randomized trial. Dis Colon Rectum. 2001;44:93-7 pubmed
    ..Glyceryl trinitrate treatment is labor intensive for patients and physicians and has not been shown to be superior to lateral sphincterotomy. ..
  22. Brisinda G, Maria G, Sganga G, Bentivoglio A, Albanese A, Castagneto M. Effectiveness of higher doses of botulinum toxin to induce healing in patients with chronic anal fissures. Surgery. 2002;131:179-84 pubmed
    ..The results also confirm that higher doses account for a higher success rate, with little increase in complications or side effects, which is probably related to the diffusion of the toxin to the external sphincter. ..
  23. Perrotti P, Bove A, Antropoli C, Molino D, Antropoli M, Balzano A, et al. Topical nifedipine with lidocaine ointment vs. active control for treatment of chronic anal fissure: results of a prospective, randomized, double-blind study. Dis Colon Rectum. 2002;45:1468-75 pubmed
    ..Our study clearly demonstrates that the therapeutic use of topical nifedipine and lidocaine ointment should be extended to the conservative treatment of chronic anal fissure. ..
  24. Scholefield J, Bock J, Marla B, Richter H, Athanasiadis S, Pröls M, et al. A dose finding study with 0.1%, 0.2%, and 0.4% glyceryl trinitrate ointment in patients with chronic anal fissures. Gut. 2003;52:264-9 pubmed
    ..The high proportion of fissures which healed in the placebo group suggests that the definition of "chronicity" needs to be reassessed. Further studies are required to confirm the optimal therapeutic strategy. ..
  25. Brisinda G, Maria G, Bentivoglio A, Cassetta E, Gui D, Albanese A. A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. N Engl J Med. 1999;341:65-9 pubmed
    ..Although treatment with either topical nitroglycerin or botulinum toxin is effective as an alternative to surgery for patients with chronic anal fissure, botulinum toxin is the more effective nonsurgical treatment. ..
  26. Bielecki K, Kolodziejczak M. A prospective randomized trial of diltiazem and glyceryltrinitrate ointment in the treatment of chronic anal fissure. Colorectal Dis. 2003;5:256-7 pubmed
    ..3% of cases while no patient had any side-effects after diltiazem. Diltiazem and glyceryltrinitrate (GTN) were equally effective in healing anal fissure but the former resulted in fewer side-effects. ..
  27. Graziano A, Svidler López L, Lencinas S, Masciangioli G, Gualdrini U, Bisisio O. Long-term results of topical nitroglycerin in the treatment of chronic anal fissures are disappointing. Tech Coloproctol. 2001;5:143-7 pubmed
    ..Headache as side effects occurred in 17 cases (77%). In conclusion, both treatments were effective for acute fissures, whereas for chronic ones NTG had a high healing rate but also a high recurrence rate. ..
  28. Nelson R. Treatment of anal fissure. BMJ. 2003;327:354-5 pubmed
  29. Nagle D, Rolandelli R. Primary care office management of perianal and anal disease. Prim Care. 1996;23:609-20 pubmed
    ..Appropriate recognition of these processes allows for outpatient, office-based intervention. With the techniques and management described in this article, many patients' symptoms can be ameliorated expeditiously. ..
  30. Minguez M, Herreros B, Espi A, Garcia Granero E, Sanchiz V, Mora F, et al. Long-term follow-up (42 months) of chronic anal fissure after healing with botulinum toxin. Gastroenterology. 2002;123:112-7 pubmed
  31. Mazier W. Hemorrhoids, fissures, and pruritus ani. Surg Clin North Am. 1994;74:1277-92 pubmed
    ..This brief treatise offers a safe and practical approach to the management of these three diseases. ..
  32. Merenstein D, Rosenbaum D. Is topical nifedipine effective for chronic anal fissures?. J Fam Pract. 2003;52:190-2 pubmed
    ..5% lidocaine and 0.3% nifedipine were applied twice daily for 6 weeks. This extremely safe, well tolerated, and effective treatment should provide family physicians with a reliable nonsurgical method for treating chronic anal fissures. ..
  33. Mentes B, Irkorucu O, Akin M, Leventoglu S, Tatlicioglu E. Comparison of botulinum toxin injection and lateral internal sphincterotomy for the treatment of chronic anal fissure. Dis Colon Rectum. 2003;46:232-7 pubmed
    ..The early (two months) and late (one year) healing rates are significantly higher in the sphincterotomy group, the two groups reaching similar healing rates only at six months. ..
  34. Jonas M, Speake W, Scholefield J. Diltiazem heals glyceryl trinitrate-resistant chronic anal fissures: a prospective study. Dis Colon Rectum. 2002;45:1091-5 pubmed
    ..Topical 2 percent diltiazem is effective treatment for glyceryl trinitrate-resistant chronic anal fissures. Side effects, mainly perianal itching, may occur in 10 percent of patients but are generally tolerated. ..
  35. Madoff R, Fleshman J. AGA technical review on the diagnosis and care of patients with anal fissure. Gastroenterology. 2003;124:235-45 pubmed
  36. Jonas M, Scholefield J. Anal Fissure. Gastroenterol Clin North Am. 2001;30:167-81 pubmed
    ..When chemical sphincterotomy fails and resting anal pressures are not elevated, as is commonly the case with patients developing fissures postpartum, an advancement flap should be considered. ..
  37. Knight J, Birks M, Farouk R. Topical diltiazem ointment in the treatment of chronic anal fissure. Br J Surg. 2001;88:553-6 pubmed
    ..Early recurrences are common but usually amenable to further chemical sphincterotomy. ..
  38. Bailey H, Beck D, Billingham R, Binderow S, Gottesman L, Hull T, et al. A study to determine the nitroglycerin ointment dose and dosing interval that best promote the healing of chronic anal fissures. Dis Colon Rectum. 2002;45:1192-9 pubmed
    ..Headaches were the primary adverse event and were dose related. Nitroglycerin ointment did not alter healing but significantly and rapidly reduced the pain associated with chronic anal fissures. ..
  39. Kua K, Kocher H, Kelkar A, Patel A. Effect of topical glyceryl trinitrate on anodermal blood flow in patients with chronic anal fissures. ANZ J Surg. 2001;71:548-50 pubmed
    ..Topical application of glyceryl trinitrate ointment seems to significantly improve the blood flow to the fissured area in the first hour. This may therefore help in the healing of chronic anal fissures. ..
  40. Heitland W. [Fistulas and fissures. Part II: fissures]. Chirurg. 2008;79:439-43 pubmed publisher
    ..As lateral internal sphincterotomy represents poses a clear danger to continence, fissurectomy combined with the excision of skin tags and any anal papilla is now the operative treatment of choice. ..
  41. Hosseini S, Sabet B, Nouri Amirkolaee M, Bolandparvaz S. A randomized clinical trial on the effect of oral metronidazole on wound healing and pain after anal sphincterotomy and fissurectomy. Arch Iran Med. 2008;11:550-2 pubmed
    ..Our results did not support the prophylactic use of metronidazole in reducing postsurgical complications after internal sphincterotomy of anal fissure. ..
  42. Mosley F, Bhasin N, Davies J, Ausobsky J. Life-threatening haemorrhage secondary to nicorandil-induced severe peri-anal ulceration. Ann R Coll Surg Engl. 2010;92:W39-40 pubmed publisher
    ..Whilst nicorandil should be considered in cases of chronic peri-anal and peristomal ulceration which fail to respond to conventional treatments, this case highlights its importance in the setting of acute surgical presentations...
  43. Hashmi F, Siddiqui F. Diltiazem (2%) versus glyceryl trinitrate cream (0.2%) in the management of chronic anal fissure. J Coll Physicians Surg Pak. 2009;19:750-3 pubmed publisher
    ..Both GTN and DTZ are equally effective in managing the chronic anal fissure. DTZ has fewer side effects, a better healing response and low recurrence rates. ..
  44. Witte M, Klaase J. Botulinum toxin A injection in ISDN ointment-resistant chronic anal fissures. Dig Surg. 2007;24:197-201 pubmed
    ..It is a simple technique with little or no side effects, that does not compromise future treatments. Its place in the first-line treatment of CAFs should be investigated further. ..
  45. Schiano di Visconte M, Di Bella R, Munegato G. Randomized, prospective trial comparing 0.25 percent glycerin trinitrate ointment and anal cryothermal dilators only with 0.25 percent glycerin trinitrate ointment and only with anal cryothermal dilators in the treatment of chronic anal fissure: a tw. Dis Colon Rectum. 2006;49:1822-30 pubmed
    ..The combined treatment for chronic anal fissure proved to be efficacious, safe, and with statistically significant better results than the other treatments analyzed. ..
  46. Bissessor M, Fairley C, Read T, Denham I, Bradshaw C, Chen M. The etiology of infectious proctitis in men who have sex with men differs according to HIV status. Sex Transm Dis. 2013;40:768-70 pubmed publisher
    ..2% vs. 6.5%, P = 0.04), HSV-2 (22% vs. 12.3%, P = 0.03), lymphogranuloma venereum (7.8% vs. 0.7%, P = 0.004), and multiple infections (17.7% vs. 8.6%, P = 0.017). Thirty-two percent with HSV proctitis had external anal ulceration. ..
  47. Vieira A, Castro Poças F, Lago P, Pimentel R, Pinto R, Saraiva M, et al. The importance of ultrasound findings in the study of anal pain. Rev Esp Enferm Dig. 2010;102:308-13 pubmed
    ..However, there was no correlation between ultrasound findings and physiological studies, and therefore could not find etiological or pathogenic factors of functional anal pain. ..
  48. Cho D. Controlled lateral sphincterotomy for chronic anal fissure. Dis Colon Rectum. 2005;48:1037-41 pubmed
    ..017). There was one recurrence in the traditional sphincterotomy group. Controlled lateral sphincterotomy could be a way of overcoming the risk of incontinence with lateral internal sphincterotomy for chronic anal fissure. ..
  49. Schmittner M, Schreiber H, Janke A, Weiss C, Blunk J, Bussen D, et al. Randomized clinical trial of perianal surgery performed under spinal saddle block versus total intravenous anaesthesia. Br J Surg. 2010;97:12-20 pubmed publisher
    ..SSB is superior to TIVA in patients undergoing perianal surgery in terms of analgesic consumption within 24 h after surgery and aspects of postoperative recovery. ISRCTN41981381 ( ..
  50. Ho K, Ho Y. Randomized clinical trial comparing oral nifedipine with lateral anal sphincterotomy and tailored sphincterotomy in the treatment of chronic anal fissure. Br J Surg. 2005;92:403-8 pubmed
    ..LAS was most effective in providing pain relief and allowing rapid fissure healing, with minimal recurrence and no increased risk of incontinence, in patients with good anal sphincter function. ..
  51. Kroft E, Warris A, Jansen L, van Crevel R. [A Dutchman from Mali with a perianal ulcer caused by cutaneous amoebiasis]. Ned Tijdschr Geneeskd. 2005;149:308-11 pubmed
    ..Primary cutaneous amoebiasis is a rare disease. Diagnosis and treatment are relatively simple but lack of familiarity with the disease may lead to misdiagnosis or diagnosis at a late stage ofthe infection...
  52. Ahmad J, Andrabi S, Rathore M. Comparison of topical glyceryl trinitrate with lignocaine ointment for treatment of anal fissure: a randomised controlled trial. Int J Surg. 2007;5:429-32 pubmed
    ..The recurrence rate is high and comparable to lignocaine ointment. It is a safe and an effective treatment of anal fissure in a South Asian population. ..
  53. Cariati A. Anal stretch plus fissurectomy for chronic anal fissure. Acta Chir Belg. 2013;113:322-4 pubmed
    ..Lateral internal sphincterotomy and anal stretch have nearly a reported 95% of good results but the first have 3-5% rates of major incontinence. ..