Anal fissure is a common proctological condition that significantly compromises the patient's quality of life. The treatment algorithms for anal fissure proposed in the literature agree on the initial conservative approach. In the case of conservative treatment failure, however, other therapies are introduced, including botulinum toxin, followed by invasive and surgical techniques. This paper presents the possibilities of different combined approaches, including botulinum toxin injection into the anal canal combined with conservative treatment, a dilator or pneumatic dilation, and surgery. Therapies combining pneumatic dilatation with conservative treatment are also presented. The publication is based on both our own practical observations and current reports. We concluded that the heterogeneous aetiology of anal fissure is a logical rationale for multidirectional treatment.