If no response to conservative pharmacologic tx refer for surgery or injection tx

¹ Topical diltiazem may be preferred d/t lower HA incidence and lower fissure recurrence vs NTG. Insufficient data to conclude whether topical CCBs are superior to placebo. Oral CCB may be as effective as topical, suggesting drug (not route) is key. Note: topical diltiazem not available commercially, but may be obtained through compounding pharmacy.
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² Topical nitrates significantly ↓ pain; 6-8 wks tx associated w/ healing in 50% of fissures; marginally superior to placebo per Cochrane review. Dose-related HA occurs in 20-30%.
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³ LIS w/ general/spinal/local anesthesia. LIS clearly superior vs uncontrolled manual anal dilation; w/ better healing rates, less incontinence. No outcome difference b/t open vs “closed” sphincterotomy, so minimal incision probably preferred. Low but real incidence of incontinence.
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⁴ Allows healing in 60-80% of fissures; superior healing rates vs placebo. Recurrence in up to 42%; may re-tx w/ similar results. Higher doses may improve healing (and be as safe as lower doses); however, no consensus on dose/site/injection frequency. Common side effects include pain at sensitive injection site and temporary incontinence of flatus (18%) and/or stool (5%). Topical nitrates may potentiate botulinum toxic effects in refractory fissures.