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Like any trauma, a condition can appear suddenly with a sharp jolt of pain. One particular condition is almost as common as hemorrhoids and has deceptively similar symptoms. But it’s not hemorrhoid; it’s a small tear in the lining of the anus called an anal fissure. Like any cut, it can heal on its own with the proper care. Sometimes, the anal fissure may become a problem and won’t go away, but in that case, there are treatment options that will help it to heal.
What is an anal fissure?
An anal fissure is a tear in the lining of the anus or rectum. It is usually caused by passing hard stools or straining the anus too hard when passing stools.
Like a cut, most anal fissures heal spontaneously in a few days, but they can be very painful until they do. Often times anal fissures can be painless and will bleed with passing stools. Some fissures, however, do not heal, but rather they persist and can get worse over time. Though even the worst anal fissures present no health risk, they can significantly decrease the quality of life and interfere with a person’s lifestyle and career.
Anyone can get an anal fissure, but they occur most frequently in children and middle-aged adults. About one in ten people will experience an anal fissure at some point in their life. The most common causes of anal fissures are constipation, chronic diarrhea, inflammatory bowel conditions, medical procedures, and childbirth. People with a history of constipation or with a tight anal sphincter are most at risk.
An anal fissure can be acute (short-term) or chronic (ongoing). If the fissure persists for more than six weeks, the problem is chronic. Chronic anal fissures are usually deep, sometimes deep enough to reveal the anal sphincter muscle.
Chronic fissures that do not heal are caught in a feedback loop. The pain irritates the inner anal sphincter muscle which then spasms. The spasms cut off blood to the area, which interferes with healing. The spasms may also make the fissure worse. The medical treatment for chronic anal fissure will be to relax the anal sphincter muscles through drugs or surgery so that the fissure can heal.
How is an anal fissure diagnosed?
The diagnosis of an anal fissure is primarily clinical and consists of a history and a visual examination of the anus. If the fissure is not immediately visible, the healthcare provider may inspect the anus using a small scope called an anoscope, but this is rare.
The visual identification of an anal fissure is all that’s required for a diagnosis. No further procedures or tests are usually required.
However, if a more serious problem is suspected, a proctologist will use a flexible sigmoidoscopy or a colonoscopy to rule out other possibilities such as cancer or Crohn’s disease.
Anal fissure treatment options
For acute anal fissures, the best treatment is time and a few lifestyle changes to aid the healing process. The majority of acute anal fissures will heal in a few days. Fissures that go on for longer than six weeks will require medications or surgery to relax the anal sphincter.
Prescription medications
Chronic anal fissures will require medications to relax the anal sphincter muscles, such as topical nitroglycerin or blood pressure medications. For severe cases, an injection of botulinum toxin A can paralyze nerves and relax the anal sphincter for several months to allow for healing.
Surgery
A colorectal surgeon will resort to surgery when a chronic anal fissure does not heal with medications or if the pain is too severe. The surgeon will perform a lateral internal sphincterotomy (LIS), an outpatient procedure done under local anesthesia which involves cutting a portion of the anal sphincter. The cut will loosen the internal anal sphincter muscle and eliminate the spasms that worsen the condition. 96% of anal sphincters heal within three weeks after this surgery. However, incontinence, including uncontrolled flatulence, will affect about 45% of patients in the months after the operation and still be a problem for 10% of patients after five years.
Home treatment
An anal fissure, like a cut on the skin, will usually heal in seven to eight days. Once the fissure has healed, home treatment will involve preventing a recurrence. Continue to drink a lot of water and eat a diet high in fiber to prevent constipation and hard bowel movements that can cause another anal fissure.
Anal fissure medications
Most anal fissures will require only non-prescription laxatives or pain relief creams to heal. Fissures that don’t heal will require medications that relax the anal sphincter to prevent the muscle spasms that worsen the condition. These medications are usually sufficient to allow the tissues to heal on their own.
Laxatives
For most people, eating a high-fiber diet will be enough to resolve constipation or hard bowel movements that damage anal tissues. Over-the-counter bulk-forming laxatives, like psyllium, stool softeners, such as docusate, or osmotic laxatives, such as magnesia, can soften and lubricate stools so that they pass more easily.
Topical anesthetics
Topical anesthetics such as lidocaine cream block the nerves that transmit pain. They can be purchased without a prescription and be applied directly to the area to provide temporary relief. A proctologist will often prescribe a lidocaine cream when treating chronic anal fissure.
Nitroglycerin
For chronic anal fissure, the first-line medication used to relax the anal muscles is topical nitroglycerin. Normally used to relax blood vessels, nitroglycerin ointment is the most effective medicine for relaxing the anal sphincter to treat anal fissure. A nitroglycerin ointment may need to be compounded by a compounding pharmacy.
Calcium-channel blockers
For patients who are unable to tolerate the side effects of nitroglycerin, topical versions of drugs that are normally used to treat blood pressure (hypertension) can be used off-label to relax the anal sphincter. The drugs of choice are nifedipine or diltiazem. Three out of four or more people with chronic anal fissures will be pain-free in two months. Nifedipine manufactured as a pill, so it will need to be compounded as a cream or ointment by a compounding pharmacy.
Botulinum toxin injection
When conservative drug therapy does not work, botulin toxin A, better known as Botox, is highly effective at relaxing the anal sphincter. Injected beneath the tissues near the anal sphincter, the botulinum toxin relaxes the anal sphincter and reduces or eliminates spasms of the inner anal sphincter muscle for about two to three months after the injection. Many people will be pain-free in a few weeks, but because there is no standard or practice, there are no reliable statistics on its effectiveness. Botulinum toxin injections, however, are very expensive, not covered by insurance, and are very painful. The use of botulinum toxin for anal fissures, like diltiazem of nifedipine, has not been approved by the FDA.
What is the best medication for an anal fissure?
The best medication for anal fissure will depend on the severity of the condition and the patient’s tolerance for side effects. For acute anal fissure, a fiber supplement and an over-the-counter topical anesthetic are usually enough to help speed up the healing process.
For chronic anal fissure, the goal of medication is to relax the anal sphincter so that the tear can heal. The most effective medication, nitroglycerin, also causes severe headaches, so patients may need to rely on less effective medication. The good news is that most drug therapies for anal fissure are highly effective.
| Best medications for anal fissure | ||||
|---|---|---|---|---|
| Drug Name | Drug Class | Administration Route | Standard Dosage | Common Side Effects |
| Metamucil (psyllium fiber) | Laxative | Oral | One packet up to three times daily | Diarrhea, gas, bloating |
| Phillips Milk of Magnesia (magnesium hydroxide) | Laxative | Oral | 60 ml of 400 mg / 5 ml once daily | Diarrhea, bad taste in the mouth, stomach cramps |
| Aspercreme Lidocaine (lidocaine cream) | Anesthetic | Topical | Apply a thin layer on the affected area every six to eight hours | Redness, blistering, dry skin |
| Rectiv (nitroglycerin cream) | Vasodilator | Topical | A one-inch strip of ointment into the anus every 12 hours | Severe headache, dizziness, low blood pressure |
| Nifedipine cream | Antihypertensive | Topical | Apply 0.2% or 0.3% cream two to four times a day | Headache, lightheadedness, low blood pressure |
| Botox (botulinum toxin A) | Neurotoxin | Injection | The dosage has not been standardized | Pain, bleeding, incontinence |
Many of the standard dosages above are from the U.S. Food and Drug Administration (FDA). Except for Rectiv, all the drugs used to treat anal fissure are prescribed off-label. There are no standardized protocols or dosages for their use in treating anal fissure. Some medications will have to be produced by a compounding pharmacy and their potency and effectiveness may vary dramatically. Dosage is determined by your healthcare provider based on your medical condition, response to treatment, age, and weight. Other possible side effects exist.
What are the common side effects of anal fissure medication?
Different classes of medications have different side effects. However, this is not a complete list, and you should consult with a healthcare professional for possible side effects and drug interactions based on your specific situation.
For most people, fiber supplements or bulk-forming laxatives will have mild side effects like gas, bloating, and, of course, mild diarrhea. These are safe medications and will not cause constipation when they’re discontinued.
Lidocaine is a safe and effective topical anesthetic. It should not be overused. When it is overused or absorbed into the body it can cause fast heart rate, confusion, tremor, and even heart attack.
Nitroglycerin is enormously effective at relaxing the anal sphincter but it causes headaches in most people. These headaches can be severe, so a healthcare provider will often prescribe a pain reliever to take with the nitroglycerin.
Nifedipine and diltiazem are generally safe medications that will have few side effects. They do lower blood pressure, so patients with normal blood pressure might get dizzy or lightheaded on these drugs.
Botulin toxin injections are very painful, usually involving 5 or more injections in the anus. Outside of the pain, botulin toxin typically has minor side effects such as redness and swelling. The most serious side effects of botulin toxin happen when it spreads to other parts of the body and kills nerves in other parts of the body. This is rare, but it can happen even weeks after the injections.
What are the best home remedies for an anal fissure?
Like a cut on the skin, the anal fissure needs time to heel. The goal of in-home treatment is to prevent constipation and hard bowel movements that will put more strain on the fissure. Relaxing the anal sphincter will also help the fissure to heal.
- Drink more water. Drinking plenty of water will make stools softer and easier to pass.
- Eat more fiber. Fiber is a bulk-forming laxative and promotes regular bowel movements.
- Use stool softeners or osmotic laxatives. Both stool softeners and osmotic laxatives increase the water content of the stools, making them softer and easier to pass without straining the sphincter.
- Take warm baths. A 10- to 15-minute warm bath or sitz bath taken three times a day will relax the anal sphincter and increase blood flow to the anus, helping to speed healing.
Frequently asked questions about anal fissures
Are anal fissures dangerous?
An anal fissure is not dangerous. It may, however, be caused by a serious medical condition, so you should talk to a healthcare provider if you experience rectal pain and bleeding.
What is the best cream for fissures?
Anal fissures will heal in most cases. Over-the-counter anesthetic creams can help people manage the pain. For chronic fissures, a physician will use prescription creams to relax the anal sphincter to give the fissure time to heal.
What causes an anal fissure?
An anal fissure is usually caused by trying to pass hard or large stools and is due to both the hardness of the stool and the tightness of the anal sphincter. Chronic diarrhea, inflammatory bowel disease, childbirth, and medical procedures can also cause an anal fissure.
Why is my fissure not healing?
Most anal fissures will heal in a few days if measures are taken such as drinking more water and eating more fiber. The fissure might not heal if constipation or hard bowel movements continue. Chronic anal fissures are often caught in a cycle of repeated damage. The pain might irritate the inner anal sphincter muscle and cause it to spasm. The spasm then pulls the fissure apart even more or blocks blood flow to the area, slowing the healing process. The goal of chronic anal fissure treatment is to relax the anal sphincter to stop the spasms.
How long do anal fissures last?
Most anal fissures will heal in seven to eight days, but it could take a few weeks. Fissures that are not healed after six weeks are chronic fissures and require the help of a healthcare provider.
How do you permanently heal a fissure?
Like a cut on the finger, fissures do heal permanently. For most people, the only therapy required is time, lots of liquids, a diet high in fiber, and taking a few warm baths every day. Chronic anal fissures are due to spasms of the anal sphincter that keep opening the fissure and even making it bigger. The goal of drug therapy or surgery is to relax the anal sphincter so that the fissure can heal on its own.
How can I treat fissure at home?
The goal of home treatment is to give the injury the space to heal by softening stools and relaxing the anal sphincter. Drinking lots of water and eating a high-fiber diet is usually enough to sufficiently soften stools, but a gentle laxative may be required. Warm baths or sitz baths three times a day will both relax the anal sphincter and increase blood flow to the injured area. Pain can be managed with a topical anesthetic such as lidocaine.
How do I know if I have a hemorrhoid or fissure?
The most common cause of anal pain is a hemorrhoid. An anal fissure is a tear in the anal lining and a hemorrhoid is a swollen vein (like a varicose vein) that balloons out with blood. They are immediately identifiable on a visual examination, but a visual self-examination of the anus is beyond most people’s ability. The only sure way to know the difference is to have a healthcare professional examine the anus.
Is Vaseline good for fissures?
Vaseline is a wound protectant. Applied over a small cut, it speeds healing by protecting the wound from further injury or contamination while providing a moist environment to heal. An anal fissure looks like a cut, but it is caused by the tissue being pulled apart. While Vaseline can provide symptom relief, the goal of anal fissure treatment is to keep the tear from being pulled apart. This is accomplished by softening the stools or relaxing the anal sphincter.
Do fissures itch when healing?
Itching is a common symptom of anal fissure but it is not caused by the healing process.
Does coconut oil heal fissures?
Coconut oil is a moisturizer. The area where most anal fissures occur, the anoderm, does not have hair follicles, sweat glands, or oil glands, so it is normally dry. Because the anoderm (the internal lining of the anal canal) looks like dry skin, coconut oil and other moisturizers are often advised for anal problems such as hemorrhoids or fissures. Neither of these conditions, however, is due to dry skin. While a moisturizer might make the area feel more comfortable, the most effective treatment is to give the fissure a chance to heal by preventing further trauma (softening stools) and loosening the anal sphincter.
Can fissures get infected?
An anal fissure can get infected and develop into an abscess, but this is very rare. Treatment of anal fissure with topical antibiotics or antimicrobial drugs is not part of the standard of care unless surgery is performed.
Related resources for anal fissure
- Anal Fissure: A Common Cause of Anal Pain
- Anal Fissures: A Real Pain
- Botox Injections for Anal Fissure or Anal Pain
- Botulinum toxin injection for treatment of chronic anal fissure: Is there any dose-dependent efficiency? A meta-analysis
- Is topical nifedipine effective for chronic fissures?
- Patient Drug Education for Diltiazem / Nifedipine Ointment