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Am Fam Physician. 2024;109(2):188-189

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Key Points for Practice

• Conservative therapy with bulking supplements and sitz baths leads to resolution of acute anal fissures in approximately one-half of patients.

• Although topical calcium channel blockers and nitroglycerin lead to resolution of approximately one-half of chronic anal fissures, topical calcium channel blockers have fewer adverse effects, such as headache.

• Botulinum toxin injections are as effective as topical therapies but can lead to transient fecal incontinence in 5% of treated patients. 

From the AFP Editors

Anal fissures are linear tears that often extend from the dentate line toward the anal verge and are most often caused by trauma from constipation or diarrhea. Fissures present with tearing anal pain that is triggered by defecation and can last for hours. Bright red blood on toilet tissue may be present. Fissures occur in the anterior midline in 73% of cases, whereas lateral or multiple fissures are atypical and may suggest Crohn disease, HIV infection, hematologic malignancies, syphilis, or tuberculosis. The American Society of Colon and Rectal Surgeons has released guidelines for the treatment of anal fissures.

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Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, Assistant Medical Editor.

A collection of Practice Guidelines published in AFP is available at

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