On the basis of our experience, we favor the following algorithm for diagnosis and therapy for an anal fissure disorder.

Due to the deficiencies in most clinical trials at hand, it is impossible to deduce evidence-based recommendations for therapy.

We miss a widely recognized definition of chronic anal fissure.

We have found that many authors do not take full account of all of the results of pharmacodynamics with regard to dosage, penetration kinetics, galenic formulation, site of application, and bioavailability of topically applied drugs.

We believe the hypothesis to be questionable at least that hypertonic anal sphincter is responsible for the formation and development of chronic anal fissures.

We therefore have serious doubts about the reasonability to reduce anal sphincter hypertonia either by medication or surgery to heal chronic anal fissures (Table 12.1).