Although the aetiology of anal fissure is not fully understood, most researchers agree on its heterogeneity. Most often the disorder is caused by mechanical trauma to the anal canal wall caused by hard stool, with constipation playing a contributory role. Increased internal sphincter tone, which is a reflex response to anal canal epithelial damage, causes anal canal ischemia, thereby preventing fissure healing. The pain caused by the fissure and the increased muscle tone discourages patients from bowel movement. In turn, inhibition of the bowel movement reflex gives rise to hard stool, which further traumatises the epithelium upon defecation, aggravating the symptoms. However, it is difficult to explain postpartum fissures with normal or even reduced muscle tone, or fissures in patients without constipation based on this theory. Puerperal hormonal changes and disturbed Gowers’ rectoanal inhibitory reflex in patients who hold bowel movements require treatment supplementation with agents that promote healing, e.g. hyaluronic acid or sucralfate. The role of biofeedback in the treatment of anal fissure is still debatable (1). Chronic and recurrent fissures often transform into submucosal fistulas and require surgical intervention, as in the case of typical fistulas.

Treatment decisions must be therefore based on appropriate patient qualification. The varied aetiology often requires combined treatment targeting different mechanisms underlying fissure formation. Combining conservative treatment with more invasive intervention and, in some cases, surgical techniques, increases therapeutic efficacy.

The main therapeutic assumption in typical fissures is to reduce internal sphincter tone using various methods, such as hot sitz baths, pharmacotherapy, mechanical or surgical techniques. Reduced tension improves blood supply to the anal canal and creates conditions for healing.

However, is monotherapy really used in the treatment of anal fissure on a daily basis?

According to European and American guidelines, treatment should comprise several permanent elements, such as:

– dietary modification – fibre and proper hydration,

– stool softeners,

– hot sitz baths,

– medications that reduce anal sphincter tone in the form of ointments (diltiazem, nitroglycerin or nifedipine).

Combined conservative treatments may include topical preparations reducing muscle tone by using a variety of targets. We often use combined treatment with diltiazem ointment and papaverine suppositories or nitroglycerin ointment and local anaesthetics (lignocaine). A randomised study from Egypt confirmed the efficacy of combined topical treatment with nifedipine gel, lidocaine hydrochloride and betamethasone (2).

Conservative treatment can be combined with other methods, including:

– dilatation with a rectal dilator or pneumatic dilatation,

– biofeedback,

– botulin toxin injections,

Botulin toxin injections may be combined with:

– pneumatic dilatation,

– surgical treatment of fissures in which sphincterotomy is not used (fissurectomy, fissurectomy with advancement flap).