An anal fissure is a small tear in the lining of the anal canal. These tears usually occur right down the middle of the back of the anus, but sometimes they happen down the middle of the front of the anus. Though small, an anal fissure is in a sensitive place and often causes severe and sharp pain during and after defecation. The pain can last for an hour or more afterward. The pain is often so severe that some people go to the emergency room for help. The fissure may bleed when defecating, but usually not much. It will appear as bright red blood on toilet paper or in the toilet bowl. Like most tears and cuts in the skin, anal fissures typically heal on their own, but sometimes they don’t. Chronic fissures—that don’t go away or keep coming back—may require serious medical treatment like drugs or surgery. In some cases, the fissure may be caused by a serious medical condition, so it is important to see a healthcare provider and follow-up as needed.
An anal fissure is a common condition and affects anyone regardless of age, sex, race, or ethnicity.
Symptoms of anal fissures include pain during defecation and sometimes minor bleeding.
Serious symptoms of an anal fissure, such as bleeding that won’t stop, may require immediate medical attention, but this is rare.
An anal fissure is usually caused by injury to the anal sphincter due to constipation, hard stools, diarrhea, childbirth, prior anal surgery, or anal sexual penetration. Other less common causes of anal fissures include tuberculosis, HIV/AIDS, anal cancer, inflammatory bowel disease (IBD), and sexually transmitted infections (STIs).
Anal fissures can be self-diagnosed but may require a medical diagnosis if they do not heal.
An anal fissure generally requires self-care to get better but may require medical treatment if it doesn’t get better or other symptoms are present. Anal fissure symptoms typically resolve with treatment within a few days to three weeks.
Treatment of anal fissures may include increased fluid intake, a high-fiber diet, fiber supplements, over-the-counter stool softeners, warm baths (to help decrease the anal spasm after a bowel movement), and prescription topical medicines. Rarely Botox (botulinum toxin) injections or surgery are needed. Read more about anal fissure treatments here.
Untreated anal fissures could result in complications like bleeding, pain, infections, fecal incontinence, anal fissure recurrence, or anal fistula.
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Most people will be aware of an anal fissure when it first tears, usually during defecation. The pain is often very sharp and may involve a small amount of blood. These are the most common early signs of an acute anal fissure.
An anal fissure is a small tear in a very sensitive place, the lining of the anus, so the most common symptoms of an anal fissure include:
Pain, especially during bowel movements
Irritation and discomfort
Itching
Minor bleeding
A bump or skin tag at the opening of the anus
The most common cause of anal pain is hemorrhoids, which are easily confused with anal fissures because they both cause pain. The symptoms are very similar. A physical examination by a healthcare provider can easily tell the difference. However, there are a few clues. First, an anal fissure hurts the most when pooping and lessens after a bowel movement. Hemorrhoids may hurt during bowel movements, but the pain is often throughout the day.
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RELATED: Hemorrhoid treatments and medications
Healthcare professionals diagnose anal fissures as acute or chronic.
An acute anal fissure is a short-term problem in which symptoms are experienced for six weeks or less.
Chronic anal fissures are a long-term complaint. Symptoms have gone on for over six weeks, or the anal fissure keeps returning. Not only do people with chronic fissure have persistent symptoms, but the fissure is often worse. While acute fissure is typically a superficial tear, chronic fissure can extend deeper and expose the sphincter muscle.
Treatments will vary. An acute anal fissure is usually treated conservatively with dietary changes, sitz baths after defecation, and stool softeners. Chronic anal fissure requires prescription topical drugs or surgery to get better.
Most anal fissures heal in a few days. Self-care is sufficient as treatment. See a doctor or other healthcare professional if the fissure does not heal for several weeks.
If the anal fissure is accompanied by other symptoms such as abdominal pain, weight loss, incontinence, or thin stools, see a doctor. The fissure may be due to a more serious condition causing the fissure. Bleeding due to fissures is usually minor, but if there’s copious rectal bleeding or bleeding that doesn’t stop, go to an emergency room. Brisk rectal bleeding is probably caused by a more serious medical condition.
Healthcare professionals typically diagnose an anal fissure from medical history and rectal examination. Examining the anus will help the clinician rule out other problems and determine a possible cause for the fissure. The clinician will focus on the appearance of the fissure—where it’s located, the appearance of the surrounding tissues, and if there are any other problems in the anal area.
If the fissure is in an atypical location, the clinician will conduct a more thorough history and physical examination to uncover the cause. Blood tests, urinalysis, and possibly medical imaging or an endoscopic examination of the anus (anoscopy), rectum (sigmoidoscopy), or large intestine (colonoscopy) may be required. Possible causes of atypical fissures include Crohn’s disease, ulcerative colitis, HIV/AIDS, tuberculosis, and anal cancer.
The most common complications of anal fissures are:
Ongoing discomfort and pain
Decreased quality of life
Bleeding
Infections
Incontinence (due to surgery)
Fistula formation
Anal fissure treatment is usually conservative, consisting of self-care. This is true even when a doctor diagnoses the fissure. Initial treatments of an acute anal fissure include:
Stool softeners (to make stools easier to pass without causing pain or worsening the fissure)
Increased fluid intake (to loosen and soften stools, making them easier to pass)
Sitting in warm water after a bowel movement to decrease anal sphincter spasm
A high-fiber diet or fiber supplements to make stools easier to pass
Chronic fissures often don’t heal without medical treatment. If an anal fissure does not heal or symptoms of an anal fissure last for several weeks, then healthcare providers prescribe topical prescription medications or perform surgery to heal the fissure:
Topical nifedipine, a calcium channel blocker, or nitroglycerin, a vasodilator, to increase blood flow to the area to help the fissure heal
Botox injections to decrease anal sphincter muscle spasm
Surgically cutting the anal sphincter to weaken the muscle’s tightness, a procedure called a sphincterotomy
Botox injections and surgery are usually reserved for anal fissures that don’t resolve with topical drugs because of complications like chronic fecal incontinence. They both have a high rate of success in resolving anal fissures. Anal fissures are completely cured in 96% of people who get a sphincterotomy and 50% to 80% of people who have botulinum toxin injections.
A few home treatments are the standard way to treat most anal fissures:
Take regular sitz baths in warm water after a bowel movement.
Eat more fiber or take fiber supplements.
Drink more water and other fluids to loosen up your stools.
Use a stool softener laxative to make bowel movements easier.
Avoid stimulant laxatives like Ex-Lax (senna) or Dulcolax (bisacodyl). They may make the problem worse by pushing out hard stools with more force.
Keep bowel movements on a regular schedule.
Stay away from spicy foods—they can worsen the pain when passing stools.
Take all the medications prescribed as instructed.
A sphincterotomy may require some special care for several weeks:
Follow the post-op instructions given to you by the surgeon
Take all medications as instructed
Avoid strenuous exercise
Take warm baths
Take fiber supplements
Don’t worry about incontinence—more than 90% of people with a sphincterotomy eventually recover full control over their bowel movements in a few years
If you have an anal fissure, it’s often hard to ignore. The good news is that it will go away in most cases. The better news is that it will improve more quickly and surely if you take care of it by eating more fiber, drinking more fluids, taking stool softeners, and indulging in a few warm baths.
Bowel movements usually provoke anal fissure pain. The pain can be intense or excruciating when passing stools and linger well after the bowel movement is finished. The anus may feel uncomfortable, sore, or itchy for the rest of the day.
An anal fissure is a cut in the anal canal, so wiping the anus sometimes won’t bother it. However, the bottom of the cut can extend to the bottom of the anus, so wiping that area might cause irritation or pain.
Like any skin cut, an acute anal fissure usually heals in a few days. See a doctor or other healthcare provider if it does not heal after a few weeks. It may be due to a more serious medical condition. Even if it is not due to a more serious condition, a chronic anal fissure usually requires treatment to get better.
Anal fissures, Johns Hopkins Medicine
Anal fissures, StatPearls
Chronic anal fissures, American Family Physician
Diagnosis and management of patients with anal fissure, American Family Physician
Anal fissure, American Society of Colon and Rectal Surgeons (ASCRS)
Anal fissures, StatPearls
Internal anal sphincterotomy, StatPearls
Chronic anal fissures: open lateral internal sphincterotomy result; a case series study, Annals of Medicine and Surgery
Treatment for anal fissure: is there a safe option?, The American Journal of Surgery
Hemorrhoid treatments and medications, SingleCare
Ulcerative colitis treatments and medications, SingleCare
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