If medical management is successful, then surgery may be avoided completely. Initial therapy includes management of stool consistency and warm baths. Several studies report similar results of approximately 44 % healing rates with 18–27 % recurrence rates in those patients (Shub et al. 1978; Hananel and Gordon 1997). Medical regimens now include the addition of sphincter relaxants including nitrate formulations, calcium channel blockers, and botulinum toxin injections after studies demonstrated decreased anal resting pressures with those treatments (Loder et al. 1994). Reported healing rates with topical nitrates range from 18 % to 85 % (Shawki and Costedio 2013); there is a notable incidence of adverse effects particularly headache (20–90 %), and recurrence rates may be as high as 30 %. A recent systemic review of randomized trials comparing topical glyceryl trinitrate to topical diltiazem (Sajid et al. 2013) demonstrated that the treatments were equally effective, but there were fewer adverse effects with diltiazem.

Injection of botulinum toxin into the anal sphincter muscle also relaxes the anal sphincter and improves circulation (Brisinda et al. 2009; Jost and Schimrigk 1994). The sphincter location and dosages of the injections vary among reported studies. Healing rates range from 41 % to 74 % (Giral et al. 2004; Arroyo et al. 2005; Menteş et al. 2006) with recurrence ranging from 0 % to 53 %. A recent meta-analysis summarized the results of studies comparing botulinum toxin to LIS (Chen et al. 2014). Combination of botulinum toxin injection and topical diltiazem was compared to LIS in a randomized trial (Gandomkar et al. 2015). In patients with a fissure of less than 12-month duration, the healing rate was 100 % in both groups, but in patients with fissures of a longer duration, the healing rate after LIS was significantly higher (86 % vs. 23 %). After LIS, 16 % of patients reported incontinence, while 4 % did after the combination treatment.

A Cochrane review of nonsurgical therapy for anal fissure in 2012 included 5031 patients (Nelson et al. 2012). The review concluded that nitrates resulted in marginally but significantly better healing rates than placebo but the recurrence was common. Botox and calcium channel blockers had similar healing rates but lower incidence of adverse effects. Two studies reviewed the results of a treatment algorithm in which patients progressed from topical ointment to botulinum toxin injections to surgery (Sinha and Kaiser 2012; Farouk 2014). The majority of patients responded to conservative therapy with 1–26 % requiring LIS.

Anal dilatation, fissurectomy, and advancement flaps are among the surgical options to LIS. In addition, partial, tailored, or limited internal sphincterotomy has been suggested to reduce the risk of incontinence.

Two methods are described. One involves dividing the internal sphincter only to the apex of the fissure; the other calibrates division of the muscle to the point of release of the anal spasm. In all three randomized trials comparing traditional sphincterotomy to the dentate line and the procedure limited to the apex of the fissure, healing rates were better in the traditional arm (Menteş et al. 2005; Elsebae 2007; Ho and Ho 2005). However, two studies reported higher rates of incontinence in that arm (Menteş et al. 2005; Elsebae 2007). Results of calibrated sphincterotomy are reported in three series; healing rates were comparable to the traditional procedure, but incontinence rates were lower (Cho 2005; Rosa et al. 2005; Menteş et al. 2008). A group of investigators attempted to determine how much of the internal sphincter could be divided without causing incontinence in women (Murad-Regadas et al. 2013). They found the likelihood of maintaining perfect continence after sphincterotomy was significantly greater when 25 % or less of the internal sphincter was divided.

Anal dilatation, typically manually controlled stretching of the anal sphincter, is performed under anesthesia in the operating room. Published healing rates vary from 40 % to 70 % with a wide range of recurrence (2–55 %) (Nielsen et al. 1993; Farouk et al. 1998; Konsten and Baeten 2000). Most troubling is the up to 40 % incidence of fecal soiling and 16 % fecal incontinence. Anal ultrasound revealed sphincter defects in 50 % of patients after anal dilatation (Nielsen et al. 1993). Because of the reported rates of soiling and/or incontinence, the procedure is not recommended.

Several modifications of anal dilatation are reported. Controlled anal dilatation with anal dilators or a pneumatic balloon dilator has been compared to LIS (Renzi et al. 2008). The procedures resulted in equivalent reduction of mean resting pressures and healing rates. Although early incontinence was reported in both groups, at 24 months, none of the pneumatic balloon dilatation patients were incontinent compared to 16 % of the lateral internal sphincterotomy patients (p < 0.0001). In a study comparing anal dilators to lateral internal sphincterotomy, there was no difference in healing rates; no incontinence was reported in either group (Yucel et al. 2009).

Fissurectomy involves resection of the fissure; the rationale is that replacing inflamed tissue with a clean wound will improve healing. A study of 43 patients with a minimum of 5-year follow-up after fissurectomy revealed that all fissures healed initially, but 11.6 % developed a recurrence (Schornagel et al. 2011). The only patient who developed new incontinence postoperatively was the one who had had a prior LIS. Mousavi and colleagues randomized 62 patients with fissures to traditional LIS or fissurectomy (Mousavi et al. 2009). Incontinence of flatus was noted in two patients after fissurectomy; no incontinence was noted after LIS. Healing rates were similar. A retrospective study comparing patients undergoing LIS to fissurectomy found similar rates of healing and incontinence, but the fissurectomy patients were statistically more likely to require additional medical and surgical therapy (Yurko et al. 2014).

Anoplasty is performed with the goal of covering the fissure bed with new well-vascularized tissue; dermal flaps are reported most commonly. A randomized trial comparing anal flaps to LIS in 40 patients found similar healing rates (85 % in the flap group and 100 % in the sphincterotomy group) with no incontinence reported in either group (Leong and Seow-Choen 1995). A retrospective study compared 30 patients undergoing LIS to 30 patients undergoing dermal flap closure (Hancke et al. 2010). The groups were comparable and denied preoperative incontinence. In the patients available for a minimum of 72-month follow-up, 71 % of LIS patients and 29 % of the flap patients reported persistent minor anorectal symptoms. No patient reported incontinence of formed stool, but 47 % of the LIS and 5.8 % of the flap group reported either incontinence to flatus or soiling. One hundred fifty patients with chronic anal fissures were randomized to conventional lateral internal sphincterotomy, V-Y advancement flap, or combined tailored sphincterotomy and V-Y advancement flap (Magdy et al. 2012) (Table 9.2). The use of flaps for recurrent fissures after sphincterotomy or in patients with weak sphincters is reported with good success (100 %) (Nyam et al. 1995).

Medical management may help avoid surgery in the majority of patients. The healing rates of botulinum toxin injection are inferior to the surgery, but there is little risk of incontinence. The standard for surgical care is currently LIS, but there is a small but significant risk of incontinence particularly in long-term follow-up. That risk must be balanced against healing rates of any alternative procedure. Tailored sphincterotomy, tailored sphincterotomy with anoplasty, and balloon dilatation show promising results. In patients with fissures without hypertonia or with preexisting incontinence, it would be especially appropriate to consider a flap procedure prior to any division of muscle.

Hemorrhoidal symptoms are common, but the incidence is difficult to determine as many people do not seek medical care for these symptoms. Since the denominator is unknown, the percentage of patients who require surgery cannot be reliably calculated. Medical management typically includes improving stool consistency, warm baths, oral medications, and topical treatments. Patients with hemorrhoid symptoms most frequently also complain of constipation although the symptoms may occur in patients with diarrhea. High-fiber diets and fiber supplements are beneficial. A systemic review of seven trials involving 400 patients comparing increased fiber intake to a control group showed benefit in reduction of bleeding and other symptoms (Alonso-Coello et al. 2006). There is little objective data to support the benefit of warm baths, but easing of symptoms is often reported by patients (Tejirian and Abbas 2005). One randomized trial comparing cold to hot baths in patients with anal pain has been reported since that review. There was no statistically significant difference between the two groups although only the patients with warm baths experienced significant improvement in their pain between days 1 and 7 (Maestre et al. 2010). A Cochrane review of phlebotonics, a heterogeneous class of drugs consisting of plant extracts (i.e., flavonoids) and synthetic compounds (i.e., calcium dobesilate), revealed potential benefit for patients with hemorrhoid symptoms including bleeding (Perera et al. 2012). Topical treatments often include creams, ointments, and suppositories. Case series showing benefit have been published, but no recent randomized comparative trials were found (Altomare and Giannini 2013).

Patients with symptoms related only to internal hemorrhoids may improve with office-based treatment. However, patients with symptomatic external hemorrhoids, significant prolapse, or mixed hemorrhoids as well as those who have failed office treatment will require surgery.

The true prevalence of anal fistulas is unknown. One study of a defined population estimated that fistulas occur in 12.3 per 100,000 men and 8.6 per 100,000 women (Sainio 1984). Surgery is frequently necessary to close the fistulas. However, because of the involvement of the sphincter muscle in most anal fistulas, treatment recommendations need to balance the success rate against the risk of postoperative incontinence.

The patient experience information emphasizes the importance of these considerations, and the outcome literature demonstrates that postoperative incontinence occurs frequently enough to influence treatment decisions. When patients and surgeons were asked to list their top five objectives of fistula surgery, both groups included continence in their top three (Wong et al. 2008). Ellis provided 74 patients with 10 scenarios of options for fistula surgery; the scenarios included published success and postoperative incontinence rates (Ellis 2010). The sphincter sparing options were ranked much higher than fistulotomy. The majority (74 %) chose a sphincter sparing procedure as their first choice. Studies vary about whether fistula recurrence or incontinence has more impact on quality of life or patient satisfaction (Sailer et al. 1998; Lunniss et al. 1994; García-Aguilar et al. 2000). One study found that postoperative soiling did not impact quality of life as measured by the Gastrointestinal Quality of Life Index (GIQLI) (Pescatori et al. 2004). Another study with a high rate of incontinence after fistulotomy (50 %) found that 87 % of patients were satisfied with the outcome (Westerterp et al. 2003). However, other investigators found a correlation between postoperative incontinence and quality of life scores (Jarrar and Church 2011). The reasons behind these differences are unclear. Finally another study using GIQLI found significant improvement in scores after successful surgery for anal fistulas (Seneviratne et al. 2009).

Most publications do not include the use of standardized instruments to survey for incontinence or anorectal physiology testing. The results are illuminating when such studies are performed. Roig and colleagues prospectively analyzed 143 patients with pre- and postoperative surveys, manometry, pudendal nerve testing, and anal ultrasounds after fistula surgery (Roig et al. 2009) Preoperative incontinence was noted in 14.2 % of patients and in 49.2 % of patients postoperatively. Incontinence scores worsened in patients after fistulotomy and endorectal advancement flap but improved slightly in patients after fistulotomy and immediate sphincter reconstruction. All surgical approaches produced increased defects in the internal sphincter on ultrasound; increased defects in external sphincter developed only after fistulotomy. The presence of defects correlated significantly with postoperative incontinence and lower manometry results. These findings demonstrate the importance of sphincter sparing surgery to avoidance of new incontinence as well as the frequency with which sphincter injury occurs.