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Anal FIssure

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Checked: 23-10-2021 by Rob Adams Next Review: 23-10-2024

Overview

Please see the:

BNSSG Anal Fissure Treatment Pathway 2024(1) for local advice on use of GTN/diltiazem and when to refer.
CKS guidelines for Anal Fissure (2) - for advice on diagnosis and management.

Red Flags

Consider malignancy in the following patients:

Patients with an unexplained anal mass or unexplained anal ulceration

Patients aged over 50 with an anal fissure is unusual so please consider other causes such as malignancy.

Refer using a suspected cancer pathway referral (for an appointment within 2 weeks) if rectal cancer is suspected. See the Lower GI - USC (2WW) page.

Refer to an appropriate specialist (with urgency dependant on clinical judgement) if another serious underlying cause, such as inflammatory bowel disease or a sexually transmitted infection (such as HIV infection), is suspected (for example if fissure looks atypical on examination).

What to do before referral

Simple anal fissures can often be managed in primary care as follows (1,2):

Treat constipation
Recommend a healthy diet and good fluid intake.
Encourage good hygiene.
Manage pain using oral analgesia and/or topical local anaesthetics.
Consider GTN 0.4% ointment for 6- 8 weeks if symptoms not settling. Alternatively diltiazem 2% ointment can be used if GTN is not appropriate (2). See BNSSG formulary for further advice.

Referral

If an anal fissure fails to respond to treatment in primary care and the referral pathway above has been followed, then consider a referral to colorectal surgery via eRS.

Surgery or botox injections for chronic anal fissures will only be considered if criteria are met as laid out in the BNSSG Anal fissure pathway (1) in the BNSSG formulary.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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