Anal Fissure: Clinical Guidelines

List of Abbreviations

IAP – internal anal sphincter

MRI – magnetic resonance imaging

RCT – randomized controlled trial

US – ultrasound examination

PRP – Platelet-Rich Plasma

Terms and Definitions

Anoderm is the epithelial lining of the anal canal, represented by stratified non-keratinizing squamous epithelium.

The anal canal is the terminal part of the digestive tract located between the lower ampullary part of the rectum and the external opening of the anus.

The "anatomical" anal canal is the area located between the outer edge of the anus and the anorectal (dentate, pectinate) line, with a length of 1.5–3.0 cm.

The dentate line is the line formed by the edges of the anal valves—pockets formed by the intestinal mucosa between the anal columns (columns of Morgagni).

The "surgical" anal canal is the distal gastrointestinal tract, including the "anatomical" anal canal and the distal rectum (from the dentate line to the anorectal ring, i.e., the attachment site of the puborectal muscle), with a length of 2.4–4 cm.

Fibrotic changes in the walls of the anal canal are morphological changes in the walls of the anal canal arising as a result of a chronic inflammatory process and including the presence of scarring of the edges and base of the fissure, a sentinel tag at the distal edge of the fissure, a fibrotic anal polyp at its proximal edge, and pectinosis.

Pectinosis is a rigid circular narrowing of the anus due to scarring of the distal edge of the internal anal sphincter.

Dyssynergic defecation is impaired coordination of pelvic floor muscles during defecation.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

An anal fissure is a linear or elliptical defect (ulcer) of the anoderm located within the "anatomical" anal canal, accompanied by increased tone of the internal anal sphincter [1–6].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

An anal fissure is a multi-etiology disease. The cause of its development is trauma to the mucosa of the anal canal, most often due to the passage of hard stools (constipation), frequent loose stools (diarrhea), or other defecation disorders [1, 5, 7–9].

The main pathogenetic mechanism of anal fissures is spasm of the internal sphincter [10–13], occurring in response to anoderm trauma [7–9]. A significant role in its occurrence is played by a predisposition to reduced nitric oxide production, which leads to increased smooth muscle tone [14]. The effect of dyssynergic defecation on the development of internal sphincter spasm is also possible [15, 16]. Predisposing factors also include the vascular factor: the inferior rectal artery does not form a developed network of anastomoses along the posterior semicircle, the density of the capillary network here is also significantly lower, and small arterial vessels supplying the anoderm pass through the thickness of the internal sphincter [17]. Consequently, the presence of its spasm further worsens anoderm perfusion, creating unfavorable conditions for defect healing [17–19]. Among additional factors hindering anal fissure healing, microbial contamination by pathogenic and opportunistic microorganisms [20–22] and the formation of bacterial biofilms on its surface [23] should be considered.

The edges and base are distinguished in an anal fissure. An acute anal fissure (up to 2 months) has clear, even edges without fibrotic changes. At the base of such a fissure, the endings of nerve fibers are exposed, which leads to severe pain syndrome and the development of internal sphincter spasm. In the absence of defecation disorders leading to anoderm trauma, an acute anal fissure epithelializes.

With continued exposure to factors damaging the anoderm, the healing process is prolonged. At the same time, fibrotic changes develop in the edges and base of the defect, preventing the epithelialization of the fissure—a chronic anal fissure is formed [1, 5, 24, 25].

Pathognomonic signs of a chronic anal fissure:

• fibrotic changes in the edges of the defect, as well as the presence of a fibrotic anal polyp at the proximal edge of the defect and/or the presence of a sentinel tag at the distal edge of the defect;

• duration of the disease history ≥ 2 months;

• the base of the anoderm defect is the internal anal sphincter.

1.3 Epidemiology of the Disease or Condition

An anal fissure is one of the most common rectal diseases. It accounts for 10% to 15% of all coloproctological diseases, with an incidence of 2–2.3 per 1000 adult population [26]. The disease most frequently develops between the ages of 30 and 50, which determines its social significance. The incidence among men and women is equal [2].

1.4 Features of Coding the Disease or Condition

ICD-10 Codes

Chapter - Diseases of the digestive system (XI):

K60.0 Acute anal fissure

K60.1 Chronic anal fissure

K60.2 Anal fissure, unspecified

1.5 Classification of the disease or condition

An anal fissure can be [27–29]:

1. By the nature of the course:

• Acute.

• Chronic.

2. By the location of the defect in the anal canal:

• Posterior.

• Anterior.

• Lateral.

1.6 Clinical presentation of the disease or condition

The main clinical manifestation of an anal fissure is burning pain in the anal area after defecation.

Some patients note pain during defecation and bleeding from the anus in the form of blood smears on stool and toilet paper.

In a chronic anal fissure, the course of the disease is undulating—periods of remission (absence of complaints) alternate with periods of exacerbation (pain in the anal area during defecation, discomfort, blood smears, etc.).

A change in the nature of the pain syndrome, a decrease in its intensity, and the appearance of symptoms such as maceration, itching, and burning in the anal area indicate the development of a complication of the anal fissure—the formation of an incomplete internal anal fistula.

2. Diagnostics, medical indications and contraindications for diagnostic methods

The criteria for establishing the diagnosis of an "anal fissure" are the presence of a linear or elliptical anoderm defect located within the "anatomical" anal canal.

The diagnosis of an "acute anal fissure" is established in the presence of a linear or elliptical anoderm defect located within the "anatomical" anal canal, a disease history duration of less than 2 months, and the absence of fibrotic changes indicating the chronic nature of the disease.

The diagnosis of a "chronic anal fissure" is established in the presence of a linear or elliptical anoderm defect located within the "anatomical" anal canal, a disease history duration of more than 2 months, and the presence of at least one sign of a prolonged chronic process:

1. scarring of the defect edges;

2. a fibrotic anal polyp at the proximal edge of the defect;

3. a sentinel tag at the distal edge of the defect;

4. the internal anal sphincter at the base of the anoderm defect.

In most cases, clinical examination data are sufficient to establish the diagnosis of an anal fissure.

At the same time, differential diagnosis is necessary to exclude erosive and ulcerative lesions of the anal canal of other origins [1, 27, 29–31]:

• tumors of the anal canal and rectum;

• anal fistulas;

• specific infections (tuberculosis, herpes, actinomycosis, syphilis, HIV infection);

• complications of caudal teratomas (in the presence of the opening of the primary embryonic tract);

• inflammatory bowel diseases with perianal complications;

• hemoblastoses;

• immunodeficiency states.

Principles of formulation of the diagnosis.

When formulating the diagnosis of an anal fissure, the nature of the disease course and the location of the defects should be reflected. Examples of diagnosis formulations are given below:

1. "Acute posterior anal fissure."

2. "Chronic anterior anal fissure."

2.1 Complaints and Anamnesis

With an anal fissure, complaints of burning pain in the anal area after defecation are typical. Some patients may complain of pain during defecation and bleeding from the anus in the form of smears on stool and toilet paper [2, 30].

When taking the history, attention should be paid to the nature of the pain, its duration, and its relationship with the act of defecation. The following predisposing factors may be present in the history: insufficient dietary fiber intake, spicy, fatty, and carbohydrate-rich foods, constipation, diarrhea [2, 32–34].

2.2 Physical Examination

• All patients with suspected anal fissure are recommended to undergo an initial primary coloproctologist consultation (examination) (B01.018.001) [1, 27, 30, 31].

GIB CLOE 4Grade of Recommendation – C (Level of Evidence – 4)

Comment: the examination is performed in the gynaecological position, with the patient lying on their back with their legs drawn up as close to the abdomen as possible, or in the knee-chest position, or, if this is not possible, in the lateral position. During the external examination of the perineal and perianal regions, attention is paid to changes in the perianal skin (hyperaemia, oozing, rashes, macerations, etc.), the shape of the anus, its gaping, the presence of scarring and deformations, as well as the condition of the inguinal lymph nodes. Then, by gently spreading the margins of the anus, the anoderm is examined for any defects. The shape of the defect (linear or elliptical), its depth and margins, changes in the edges, and the presence of a sentinel tag are noted. During a digital transrectal examination of the rectum, attention should be paid to the presence of an anoderm defect and its location, the condition of the edges of the anal fissure, the presence or absence of fibrous changes in the anal canal, and concomitant diseases of the anal canal and the lower ampullary rectum (haemorrhoids, anal fistula, tumour process, etc.). The presence of clinical signs of internal sphincter spasm characteristic of an anal fissure — a retracted and spastic distal edge of the internal anal sphincter — should be determined.

2.3 Laboratory Diagnostics

Specific laboratory diagnostics for anal fissures do not exist. Laboratory diagnostic tests should be performed in patients during the preparation and planning of surgical intervention to exclude concomitant diseases and conditions, as well as when differential diagnosis is necessary.

2.4 Instrumental Diagnostics

• In patients with an anal fissure, anoscopy, sigmoidoscopy, and colonoscopy are not recommended without analgesia due to the presence of pronounced pain syndrome. If it is necessary to clarify the diagnosis and perform a differential diagnosis of the underlying disease, it is recommended to perform the aforementioned examinations under analgesia [1,11,27].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

Comment: it is advisable to perform sigmoidoscopy and colonoscopy in patients over 40 years of age if concomitant diseases of the large intestine, including malignancies, are suspected.

• In patients with an anal fissure without clear clinical signs of internal sphincter spasm according to physical examination data, study of the functions of the rectal (sphincter) apparatus (A05.19.003) by sphincterometry is recommended to objectify the presence of internal sphincter spasm [1,11,35-37].

GCR CLEL 3Grade of Recommendation — C (Level of Evidence — 3)

Comment: this method makes it possible to assess the total contractile activity of the external and internal anal sphincters. The following parameters are evaluated: tone and voluntary contraction strength of the anal sphincters. The magnitude of tonic tension characterizes the internal anal sphincter to a greater extent. During voluntary contraction, the contractile activity of the striated muscles of the external sphincter and pelvic floor is assessed. Internal sphincter spasm is confirmed in the presence of at least one of the following manometric signs:

1. elevated mean pressure in the anal canal at rest;

2. presence of ultra-slow waves.

Method: the patient is placed on a couch in the lateral decubitus position with knees flexed, and the probe is inserted into the anus to a depth of 4.0-5.0 cm. Data recording is performed 3-4 minutes after probe insertion — the time required for the patient to adapt to the examination and for the anal reflex caused by probe insertion to subside. To quantitatively assess the function of the rectal sphincter apparatus, the pressure values in the anal canal at rest and during voluntary contraction are used.

• In patients with an anal fissure without clear clinical signs of internal sphincter spasm according to physical examination data, study of the functions of the rectal (sphincter) apparatus (A05.19.003) by profilometry is recommended. This study is a more sensitive method for diagnosing internal sphincter spasm compared to the study of the functions of the rectal (sphincter) apparatus (A05.19.003) by sphincterometry [1,11,36-38].

GCR CLEL 3Grade of Recommendation — C (Level of Evidence — 3)

Comment: profilometry is a method for assessing pressure in the lumen of a hollow organ. Anorectal profilometry provides registration of pressure in different planes along the entire length of the anal canal. Using a computer program, a pressure distribution curve is plotted, and the maximum and mean pressure values, as well as the asymmetry coefficient, are calculated. The processing program provides for the analysis of pressure data at any level of the cross-section of the anal canal.

Internal sphincter spasm is confirmed in the presence of at least one of the following manometric signs:

1. elevated mean pressure in the anal canal at rest;

2. elevated maximum pressure in the anal canal at rest;

3. presence of ultra-slow waves.

Method: the examination is performed with the patient in the lateral decubitus position with knees flexed. After preliminary calibration, a disposable 1-48 channel manometric catheter is inserted into the patient's rectum to a depth of up to 6 cm. The fluid perfusion rate through the catheter is set at 1 ml/min. While withdrawing the catheter from the rectum at a rate of 1 mm/sec, pressure is recorded throughout its displacement. Data analysis is performed using a computer program with the construction of a graph reflecting the pressure distribution in the anal canal.

2.5 Other Procedures

Additional instrumental and laboratory examinations are performed for differential diagnosis.

• In patients with an anal fissure without signs of spasm of the internal anal sphincter of the rectum according to physical and instrumental examination data, and with suspicion of an erosive and ulcerative lesion of the anal canal of specific etiology, for the purpose of differential diagnosis and exclusion of complications, the following examinations are recommended [1,27,29-31,39]:

1. Transrectal ultrasound of the rectum (A04.19.001.001).

2. Colonoscopy (level of examination — terminal ileum) (A03.18.001).

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 General principles of treatment for acute and chronic anal fissure

Treatment of acute and chronic anal fissures pursues the following goals:

1. normalisation of bowel movements;

2. relief of pain syndrome;

3. effect on the wound healing process;

4. relaxation of the internal rectal sphincter.

3.2 Treatment of acute anal fissure

• Conservative therapy is recommended for all patients with the aim of epithelialization of an acute anal fissure [4].

GCR ALEL 1Grade of Recommendation — A (Level of Evidence — 1)

3.2.1 Diet therapy and normalisation of gastrointestinal tract activity using laxatives

• All patients with an anal fissure are recommended to consume an adequate amount of fluids and dietary fiber to normalise gastrointestinal tract activity and eliminate constipation. In cases where bowel function cannot be normalised through diet, it is recommended to use bulk-forming laxatives (ATC A06AC), osmotic laxatives (ATC A06AD), preparations containing macrogol** (ATC A06AD15) or lactulose** (ATC A06AD11) in order to establish regular formed stools in the patient [1,11,27,40-43].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

Comment: the patients' diet should include foods rich in plant fiber and a large amount of fluid. It has been proven that the daily intake of 25 grams of dietary fiber increases stool frequency in patients with chronic constipation. Fluid intake of up to 1.5–2 litres per day increases stool frequency and reduces the need for laxatives in patients adhering to a high-residue diet. Traditionally in our country, wheat bran, kelp, and flaxseed in their natural form are used as sources of dietary fiber.

3.2.2 Conservative therapy

• Conservative therapy aimed at relieving pain syndrome is recommended for patients with an anal fissure. For topical use, combination drugs for the treatment of haemorrhoids and anal fissures (ATC C05AX03) containing anaesthetics, paracetamol** (ATC N02BE01) are used; if its efficacy is insufficient, medicinal products from the propionic acid derivative groups (ATC M01AE) or pyrazolone groups (ATC N02BB) are used [1].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

• In patients with an anal fissure, in order to influence the course of the wound healing process, it is recommended to use complex medicinal products from the group of combination drugs for the treatment of haemorrhoids and anal fissures (ATC C05AX03) [1,26].

GCR CLEL 2Grade of Recommendation — C (Level of Evidence — 2)

3.2.3 Medical relaxation of the internal anal sphincter

• For patients with uncomplicated anal fissure, local medicinal products (lidocaine + nifedipine) are recommended to achieve relaxation of the internal sphincter [4,46,47], which allows for healing of acute fissures in 83% of patients 4 weeks after initiation of treatment in the absence of complications, with a disease recurrence rate of 2.6% [101]. In the treatment of chronic anal fissures, the use of lidocaine + nifedipine rectal and external gel allows for healing and effective elimination of spasm in 77.5% of patients by day 21 of treatment, with a mean epithelialization time of 17 ± 3 days and no complications [102].

GCR CLEL 2Grade of Recommendation — C (Level of Evidence — 2)

• For patients with anal fissure, a single injection of #botulinum toxin type A into the internal anal sphincter is recommended [2-5,48-63]. The drug is administered once under the guidance of a two-bladed operating rectal speculum into the internal anal sphincter under topical or local anesthesia at a total dose of 80 IU (administered at 4 points according to the clock face: at 1, 5, 7, and 11 o'clock).

GCR BLEL 1Grade of Recommendation – B (Level of Evidence – 1)

Comment: if spasm of the internal anal sphincter is eliminated after a single administration of the drug, epithelialization of the anal fissure is observed in 78% of patients. When this drug is used as monotherapy, the recurrence rate may reach 42% [4,49,52,57]. However, the high safety profile of #botulinum toxin A in monotherapy allows for its repeated use [54,55,58].

• For all patients with anal fissure, conservative therapy for no more than 8 weeks is recommended to achieve healing of the anoderm defect [61].

GCR BLEL 2Grade of Recommendation – B (Level of Evidence – 2)

3.3 Treatment of chronic anal fissure

3.3.1 Conservative therapy of chronic anal fissure

• For all patients with chronic anal fissure, conservative therapy in accordance with the guidelines for the treatment of acute anal fissure (see Section 3.2. "Treatment of Acute Anal Fissure") is recommended for symptomatic therapy and when surgical treatment is declined [2-5,12,51-66].

GCR BLEL 1Grade of Recommendation – B (Level of Evidence – 1)

3.3.2 Surgical treatment of chronic anal fissure

• For patients undergoing treatment for chronic anal fissure, the scope of surgical intervention is recommended to be limited to relaxation of the internal anal sphincter [1,4,47,58,61,63,65-71,73].

GCR BLEL 2Grade of Recommendation – B (Level of Evidence – 2)

Comment: avoiding excision of the anal fissure helps prevent the formation of a large, long-healing wound in the anal canal, helps reduce pain intensity and the severity of anal incontinence, improves quality of life, and shortens the duration of temporary disability, while not worsening long-term treatment outcomes [61,63,65,66,71,73]. Excision of the fissure is indicated for patients with fibrous polyps of the anal canal greater than 1 cm that prolapse during defecation and cause difficulty with perianal hygiene, as well as those combined with a sentinel tag. In this case, they must be excised en bloc with the anal fissure; in other cases, surgical intervention can be limited exclusively to eliminating the spasm of the internal sphincter [61,65,66,71,72].

Fissure excision technique: the procedure consists of excising the fissure along its plane together with fibrotically altered tissues within healthy margins, extending the wound edges onto the perianal skin 1.5 – 2.0 cm from the anal verge [1]. In cases where a posterior incomplete internal fistula forms against the background of a chronic anal fissure, the surgery is performed according to the aforementioned technique and supplemented by probing the fistulous tract and excising it over a rectal probe. When the fistulous tract involves the fibers of the internal and/or external sphincter, relaxation of the internal anal sphincter is not performed.

• For patients with chronic anal fissure, excision of the anal fissure (A16.19.003.001) combined with medicinal relaxation of the internal sphincter using #botulinum toxin type A is recommended [62,72,74-79]; after fissure excision, a single injection of #botulinum toxin type A into the internal anal sphincter is performed. The drug is administered at a dose of 40 IU (10 IU is injected at each of 4 points according to the clock face: at 1, 5, 7, and 11 o'clock).

GCR BLEL 2Grade of Recommendation – B (Level of Evidence – 2)

Comment: medicinal relaxation of the internal sphincter with #botulinum toxin type A at a dose of 40 IU combined with fissure excision achieves a positive treatment outcome in 86% of cases, with the incidence of transient anal incontinence remaining within 7% [62]. Furthermore, the use of this drug is advisable in patients at high risk for postoperative anal sphincter insufficiency [79]. Elimination of internal anal sphincter spasm after drug administration leads to epithelialization of the anal fissure in 33-96% of patients [4,52-56]. The recurrence rate may reach 42% [4,49,52,57], but repeat administration of the drug is possible [54,55,59].

• For the treatment of chronic anal fissure, patients are recommended to undergo division of the anal sphincter (A16.19.014) via lateral subcutaneous sphincterotomy with or without additional excision of the anal fissure (A16.19.003.001) [71, 80].

GOM ALOE 1Level of Evidence – A (Level of Data Reliability – 1)

Comment: contraindications: patients at high risk of developing persistent postoperative anal incontinence (advanced age, history of multiple and complicated deliveries, clinical signs of perineal descent) [81–85].

Complications [11, 86]:

1) hematomas in the sphincterotomy area;

2) abscesses in the sphincterotomy area;

3) fistula formation in the sphincterotomy area;

4) postoperative anal sphincter insufficiency.

The fissure healing rate after sphincterotomy ranges from 88% to 100%, with the incidence of transient anal incontinence ranging from 8% to 30% at a follow-up of up to 6 years [53, 81, 87–95]. Open and closed lateral sphincterotomy techniques are comparable in terms of fissure epithelialization and recurrence rates [53, 57, 80, 86, 96]. At the same time, open lateral subcutaneous sphincterotomy doubles the risk of postoperative anal incontinence [97].

3.3.3 Biological therapy for anal fissure (use of autologous platelet-rich plasma, PRP therapy)

• To stimulate reparative processes and accelerate tissue defect healing in addition to relaxation of the internal anal sphincter, patients with chronic anal fissure are recommended to receive injections of autologous platelet-rich plasma. Administration of autologous platelet-rich plasma (PRP therapy) accelerates anoderm defect healing, reduces the severity of clinical symptoms, and decreases patients' need for analgesics [99, 100]. To collect blood, venous access is established, and 15 ml of blood is drawn into a tube. Next, the sterile tube for preparing autologous platelet-rich plasma is placed in a laboratory medical centrifuge for 5 minutes at 1500 rpm. Then, 3 ml of the obtained autologous plasma is injected intraoperatively into the base of the postoperative wound until its edges are elevated.

GCR BLEL 2Grade of Recommendation – B (Level of Evidence – 2)

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• All patients who have undergone surgical treatment for anal fissure are recommended to undergo daily dressings in the postoperative period until wound healing, consisting of cleaning the wounds with antiseptic and disinfectant solutions (ATC D08A) and applying anti-inflammatory and wound-healing ointment bases to the wound surface to reduce the risk of inflammatory complications [1, 27].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

• All patients who have undergone surgical treatment for anal fissure are advised to undergo dietary modification in the postoperative period until wound healing to establish regular soft stools [1, 27].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

• All patients who have undergone surgical treatment for anal fissure are recommended to have a follow-up consultation (examination, consultation) with a coloproctologist (B01.018.002) to prevent complications and disease recurrence [1, 27].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

5. Prevention and Dispensary Observation

5.1 Prevention

• All patients with the onset of initial symptoms characteristic of anal fissure are recommended to have a preventive consultation (examination, consultation) with a coloproctologist (B04.018.002) to determine the tactics of preventive measures aimed at preventing the development and progression of the disease [1, 27].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

Comment: the fundamental basis for preventing the development of anal fissure is the normalization of gastrointestinal tract function, elimination of constipation, and adherence to hygiene regimens. Timely diagnosis and treatment of the disease can significantly improve prognosis and reduce the likelihood of complications.

5.2 Prevention of infectious wound complications after surgical treatment

• In patients undergoing surgical treatment for anal fissure who have extensive wounds or immune status disorders, the administration of systemic antibacterial drugs (ATC J01), which may be used parenterally or orally, is recommended to prevent wound infection [1,27].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

5.3 Dispensary follow-up

• All patients who have undergone surgical treatment for anal fissure are recommended to have a follow-up visit (examination, consultation) with a coloproctologist (B04.018.001) at 2 weeks, 1 month, and 1 year postoperatively during the first year after surgery to improve disease control and prevent recurrence [1,27].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

6. Organization of Medical Care

Medical care, with the exception of medical care within the framework of clinical approbation, is organized and provided in accordance with:

1. Article 76 of Federal Law of the Russian Federation No. 323-FZ dated November 21, 2011 (as amended on December 29, 2025) "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation" (with amendments and additions, entering into force on April 1, 2026), regarding the development and approval of clinical guidelines (treatment protocols) on the provision of medical care by medical professional non-profit organizations;

2. Order of the Russian Ministry of Health No. 642n dated October 27, 2025 "On Approval of the Procedure for Applying Clinical Guidelines";

3. Order of the Ministry of Health and Social Development of the Russian Federation No. 206n dated April 2, 2010 (as amended on February 21, 2020) "On Approval of the Procedure for Providing Medical Care to the Population with Colonic, Anal Canal, and Perineal Diseases in Coloproctology";

4. Order of the Russian Ministry of Health No. 203n dated April 14, 2025 "On Approval of Criteria for Assessing the Quality of Medical Care".

6.1 Indications for hospital admission

Surgical treatment of chronic anal fissure is performed in specialized coloproctology departments in an inpatient or day-care setting. Surgical interventions may be performed in outpatient settings, day-care settings, including short-stay inpatient units.

6.2 Indications for patient discharge from a medical organization

Indications for patient discharge from the hospital are:

1. uncomplicated course of the early postoperative period (absence of dysuria, increased bleeding, etc.);

2. absence of purulent-septic postoperative complications;

3. controlled pain syndrome with the possibility of its relief by oral administration of analgesics (ATC N02B Other analgesics and antipyretics).

7. Additional Information

Negative factors affecting treatment outcomes include:

1. development of infectious complications;

2. bowel dysfunction (diarrhea or constipation);

3. patient non-compliance with activity restrictions and dietary recommendations.

Criteria for Evaluating the Quality of Medical Care

Criteria for assessing the quality of primary health care in adults with anal fissure (ICD-10 codes: K60.0, K60.1, K60.2)

Quality assessment criteria for specialized medical care in adults with anal fissure (ICD-10 codes: K60.0, K60.1, K60.2)

Outcome quality assessment criteria for medical care in adults with anal fissure (ICD-10 codes: K60.0, K60.1, K60.2)

References

Appendix A1. Working Group Composition

All members of the working group are members of the Association of Coloproctologists of Russia.

There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of the clinical guidelines:

1. Coloproctologists.

2. Surgeons.

3. Gastroenterologists.

4. General practitioners.

5. General practitioners (family physicians).

6. Endoscopists.

7. Nursing staff.

8. Medical students, residents, postgraduate students.

Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions).

Table 2. Level of Evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions).

Table 3. Grade of Recommendation (GoR) grading scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions).

Procedure for updating clinical guidelines.

The mechanism for updating the clinical guidelines provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or the presence of justified additions/comments to previously approved clinical guidelines, but no more than once every 6 months.

Appendix A3. Reference Materials

No.

Appendix B. Physician Action Algorithms

Appendix B1. Patient Diagnostic Algorithm

Appendix B2. Patient Treatment Algorithm

Appendix C. Patient Information

Disease Information. Anal fissure is a condition characterized by a defect in the surface epithelium of the anal canal. The most common cause of acute anal fissures is trauma to the surface epithelium of the anal canal caused by the passage of hard stool (constipation). As a result of the defect, anal sphincter spasm develops, leading to impaired blood supply to the anoderm and severe pain syndrome. Due to the inflammatory process, the edges of the defect become dense and scarred, forming a chronic anal fissure.

Patients with an anal fissure are primarily concerned with pain in the anus after defecation; minor bleeding in the form of smears on the stool and toilet paper may also be observed. If medical attention is sought untimely, complications such as anal fistula formation and cicatricial anal stenosis may occur.

When a patient visits a coloproctologist, after collecting complaints and medical history, an examination of the perianal area and digital rectal examination are performed, and further examination is prescribed if necessary. If the patient has an acute anal fissure, conservative therapy is prescribed. In turn, the main treatment method for chronic anal fissure is surgical intervention. The surgery consists of eliminating the anal sphincter spasm and, if necessary, excising the fissure. Sphincter spasm can be eliminated by medical relaxation or surgical intervention.

Adequate surgical treatment of chronic anal fissures achieves recovery in 98–100% of treated patients.

Information required in the postoperative period. In the postoperative period, during the first 1-3 months after surgery, hygienic measures (washing with cool water, sitz baths with chamomile decoction) and regulation of stool frequency and consistency are important. It is necessary to achieve regular daily soft stools that do not injure the wound surfaces in the anal canal and perianal area.

Smoked, salted, and marinated foods, cocoa, and chocolate are excluded from the diet; fried dishes, sausages, and rye bread are partially restricted. Foods high in fiber and ballast substances (found in plant-based products, primarily grains) are necessary. Foods that help normalize stool include fresh kefir, sour milk (prostokvasha), and acidophilus. Prunes soaked in water, figs, their infusions, plum juice, boiled beets, and dried fruit puree have a positive effect. Among first courses, soups and cabbage soups based on strong vegetable broth are beneficial.

A laxative effect is produced by grated carrots, a raw apple, sour milk, and 5-7 prunes washed and soaked in boiling water overnight, eaten on an empty stomach. In addition, with a generally satisfactory condition, walks and light physical activity are indicated. Morning gymnastics, physical exercises focusing on the abdominal muscles, and brisk walking are recommended.

Pharmacotherapy for constipation should be carried out with great caution, in short courses, under medical supervision.

Several additional recommendations for constipation:

1. consult your physician to find out which of the above recommendations apply to you;

2. drink 4-8 glasses of fluid per day;

3. your diet should include foods that promote intestinal peristalsis. We recommend whole grain bread, bran crispbreads, porridges (buckwheat, oatmeal, wheat, pearl barley with milk or vegetable oil), and cereal dishes. Include fiber-rich foods in your diet (dietitians recommend adding raw vegetables and fruits, nuts, and sprouted wheat to milkshakes). Try oatmeal cookies and cornflakes;

4. apples, figs, dates, and tea with lemon work well for some patients;

5. prune decoction in the morning and at bedtime is beneficial;

6. be sure to add bran to your food, starting with one teaspoon per day. Then, this amount should be increased to 4-6 spoons per day. Increasing the dose too quickly can cause loose stools and bloating. Try adding bran to porridges, rice or potato casseroles, and dairy products.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Numerical Rating Scale (NRS)

Russian Title: Numeric Rating Scale (NRS).

Original Title (if applicable): The Numeric Pain Rating Scale (NPRS).

Source (official developer website, validation publication): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647033/pdf/main.pdf, https://ascpt.onlinelibrary.wiley.com/doi/abs/10.1038/clpt.1983.159?sid=nlm%3Apubmed

Type: rating scale.

Purpose: the scale is designed to determine pain intensity and allows evaluation of the subjective pain sensations experienced by the patient at the time of examination.

Content (template):

Key (interpretation): according to the recommendations.

Notes: this method of subjective pain assessment involves asking the patient to mark a point on a 10 cm graduated line that corresponds to the degree of pain severity. The left boundary of the line corresponds to the definition.