Key Concepts

• Acute anal fissures (symptoms <6 weeks) are typically treated first with nonoperative, conservative management with high healing rates.
• Calcium channel blockers have similar efficacy rates with topical nitrates and fewer side effects. They are considered first line of treatment for chronic fissures.
• Botulinum toxin injection has slighter higher efficacy in addressing symptomatology than topical therapy, and it is considered second line of treatment for chronic anal fissures.
• Lateral internal sphincterotomy (LIS) has superior healing rates than pharmacologic treatment for chronic anal fissures; however, there is an increased risk for permanent minor incontinence. Open and closed techniques of LIS yield similar healing rates.
• Anocutaneous flaps represent a safe surgical alternative for anal fissures with decreased anal sphincter tone. In addition, advancement flaps can be used in combination with botulinum toxin injection and LIS for expediting primary wound healing.
• Ninety percent of anal stenosis cases are a result of inappropriately performed hemorrhoidectomy.
• Mild anal stenosis can frequently be managed with nonoperative treatment.
• Moderate and severe anal stenosis will require surgical treatment.
• Sphincterotomy, stricturotomy, and stricturectomy should be followed by reconstructive procedures reintroducing the epithelial or mucosal coverage into the anal canal.
• Reconstructive options involve the rectal advancement flap and several flaps utilizing the anoderm and perirectal skin.
• Management of anal stenosis in Crohn’s disease should be based on optimization of medical therapy combined with dilations; however, a significant number of patients will require diversion.