Anal Fissure

An anal fissure is a common condition where there is a painful tear in the lining of the anus, the backside opening where feces is excreted. It is often described as feeling like passing broken glass. 1

Typical anal fissure symptoms are a sensation of tearing, ripping or burning and usually a small amount of bright red bleeding during and after a bowel movement. While the condition can be very painful, it is not usually serious.

It is estimated that about one in 10 people may have an anal fissure in their lifetime, though it is not possible to establish a precise figure, because some people may be too embarrassed to discuss the condition with their healthcare provider, and it is often misattributed to hemorrhoids. 2

Anal fissure treatment generally involves softening the stool, avoiding constipation where possible and practicing good hygiene. Anal fissures typically heal within six weeks. An anal fissure that lasts for more than six weeks is called a chronic anal fissure. Occasionally, surgery is required to repair the tear.

Both males and females can be affected and, while anal fissures may occur at any age, they are primarily seen in young adults. 3

Anal fissure may be classed as:

1. Acute anal fissure, which clears up within six weeks. This is the most common type, and normally appears as linear with clear edges.
2. Chronic anal fissure, which persists for more than six weeks. Chronic anal fissure healing time varies. Without treatment, it is possible to have an anal fissure for years.

A chronic fissure is usually deeper than an acute anal fissure and is often associated with an external skin tag. Chronic fissure is usually treatable, but recurrence of the fissure after treatment is common. 1

An anal fissure may also be classed as: 4 5

• Primary: due to local trauma, such as constipation or vaginal delivery of a baby
• Secondary: due to an underlying condition process, such as ulcerative colitis Crohn’s disease or chlamydia

The most common anal fissure symptoms may include: 6 7

• A sharp, searing or burning pain in or around the bottom, which tends to be worse when passing feces and for about an hour or so afterwards
• Some bleeding, usually bright red on the toilet paper or stool
• Itching 3

Less common anal fissure symptoms may include: 1 8

• Spasms or a tightening feeling in the anus when feces is excreted
• A sentinel pile, a tag of skin which sometimes develops on the edge of the anus, below the fissure
• Abscesses: painful boil-like swellings near the anus filled with pus, which may lead to a fistula – a tunnel from the anal canal to the external skin, which may have a foul-smelling mucus discharge

An anal fissure can occur when there is overstretching of the anal canal, which causes the lining to tear. Common causes include a large, hard or otherwise traumatic bowel movement, or anal penetration. 9

Subsequent bowel movements stretch the area, meaning that healing is hindered. The anal sphincter may spasm as a result of anal fissure, restricting blood supply to the area and further hindering the healing process.

In children especially, putting off bowel movements to avoid the associated pain may worsen constipation and exacerbate the problem.

Causes of anal fissure may include the following.

Anal fissure most commonly occurs due to constipation. Lots of factors may cause constipation, but the most common include: 7 10

• Not eating enough fiber
• Not drinking enough fluids
• Some medications, particularly strong painkillers, such as opioids
• Not exercising or being less active
• Frequently ignoring the urge to defecate
• Changing diet or daily routine
• Anxiety or depression
• Some medical conditions, such as an underactive thyroid gland

Read more about persistent constipation and possible treatments ».

Anal fissure can occur in pregnancy. During pregnancy, women often experience constipation due to the increased weight of the baby putting pressure on the rectum, the final segment of the digestive system, which stores feces until a person is ready to defecate.

Childbirth causes anal fissure in about one in 10 women.

Other possible causes of anal fissure include: 6 11

• Persistent diarrhea
• A sexually transmitted infection, such as anal herpes or chlamydia, which cause the tissues to become soft and fragile
• Inflammatory bowel disease (IBD), meaning ulcerative colitis or Crohn's disease
• Trauma, for instance from rough or inadequately lubricated anal intercourse, or other insertion of foreign objects
• Unusually tight anal sphincter muscles or anal spasm
• Previous anal surgery
• Anal cancer can have similar symptoms to benign anal fissure
• Certain other cancers, e.g. leukemia

Often, no clear cause for an anal fissure can be found. They are associated with tight anal sphincter muscles, though the cause of this is unknown.

A doctor may diagnose anal fissure based on a description of the symptoms and a physical examination.

The physical examination usually involves gently separating the buttocks to allow a doctor to see the area around the anus.

Most fissures appear in the 12 or 6 o’clock position. Those in other locations are likely to be associated with an underlying disorder, such as Crohn’s disease.

A doctor will usually avoid inserting anything into the anal canal, such as a gloved finger or small instrument, as this can cause substantial pain and is often unnecessary for provisional diagnosis. 3

If there is recurring or chronic anal fissure, endoscopy procedures to look inside the body may be recommended to look for underlying causes. These are avoided in cases of an acute anal fissure, as they are not normally well tolerated. Often, the patient is at first treated solely on the basis of symptoms. If needed, procedures may include:

This involves inserting a thin, flexible tube with a light and camera on the end into the anal canal. Sometimes, topical anesthetic is used to facilitate an anoscopy.

Those who have a chronic or recurrent anal fissure after surgical therapy may be evaluated further with anoscopy and sigmoidoscopy, a procedure similar to anoscopy, but which also examines the lower colon. 12

Sometimes, a colonoscopy procedure is used to look for the presence of an underlying condition that may be causing an anal fissure, such as irritable bowel syndrome (IBS). This is similar to an anoscopy and sigmoidoscopy, but which also examines the entire colon.

Read about Preparing for a Colonoscopy ».

Wrongful diagnosis of anal fissure can also occur because it is more common than some conditions with similar symptoms. This may result in other conditions going undetected and untreated, such as infection and, though it is rare, anal cancer. 13 This can occur as anal fissure is more common and may have similar symptoms. Though medical attention should always be sought where there is any bleeding from the anus, the Ada app can help you check your symptoms. Download the app or find out more about how it works.

Treatment of an anal fissure primarily aims to ease the pain.

Anal fissure treatment generally begins with following a high-fiber diet, as well as maintaining sufficient fluid intake to soften feces and prevent further damage to the area while the wound is healing. Pain medication will usually also be prescribed.

Usually, an anal fissure will heal with home treatment. In the case of chronic anal fissure, however, occasionally surgery will be recommended.

Anal fissure pain relief and other medicines may include: 11 14

This should be applied before going to the toilet. Anesthetic creams and ointments can be obtained by prescription or over the counter. Anesthetic ointments should only be used for short periods of up to about five to seven days, otherwise the skin around the anus may become irritated.

Topical steroids may be recommended to ease swelling if it is severe. This may help to relieve pain and any itching. Steroids should not be used for more than one week at a time to avoid side effects, such as skin thinning or enlarged blood vessels. 7

Ibuprofenand paracetamol can help to ease pain. Opioids should be avoided, as this can cause constipation, which may worsen the condition and is potentially addictive.

An anal fissure will heal more easily if feces is kept soft, so that it can pass more easily. A diet involving plenty of high-fiber foods may help, such as fruit, vegetables, whole grains, nuts and seeds.

Medication that works as a stool softener may also be obtained on prescription or bought over the counter at pharmacies.

These medications may be prescribed for chronic anal fissures, present for six weeks or more. This is applied to the skin to reduce the anal sphincter pressure and can decrease pain and facilitate further healing. Side effects include headache, so the correct amount must be used.

Other general measures that are recommended alongside medicine for anal fissure may include: 6 11

Washing the area carefully with water after using the toilet, to avoid irritation and infection. Soap should be avoided as this may cause irritation, and the area should be gently dried.

Sitz baths for anal fissure may be recommended as they are thought to soothe and relax the anus muscles, relieving some of the painful internal sphincter muscle spasm. This involves sitting in plain, non-soapy water after defecation.

Measures to avoid constipation and keep feces soft to help heal an anal fissure may include: 7 10

• Eating plenty of fiber, such as is found in fruit, vegetables, cereals and wholemeal bread
• Drinking plenty of liquids to soften stools. Adults should aim to drink two litres or more each day. It is best to avoid alcoholic drinks as they can cause dehydration.
• Not putting off defecation, which can lead to bigger and harder stools forming, which may exacerbate the problem

There are further clinical treatments available for people who do not respond to topical therapy and home treatment measures. These may include: 7 14

Also known as botulinum toxin, botox, which temporarily paralyzes muscles for up to three months, can be injected into the anal sphincter. This may be done without anesthesia or sedation. Botox treatment may lead to temporary, mild anal leakage of gas or feces.

The type of surgery recommended for treating an anal fissure is normally sphincterotomy, which aims to relax the anal sphincter. A surgeon cuts the muscle in order to loosen the anal muscle, therefore improving blood supply and aiding healing. Incontinence is a possible complication from this surgery, so it is only recommended to people whose symptoms have persisted despite medicine for at least one to three months. Anal fissure surgery recovery time varies from person to person.

Complications of anal fissure may include: 15 16

• Chronic anal fissure: the tear fails to heal. Over time, this can cause extensive scar tissue at the site of the fissure.
• Incontinence: This may result from surgery to treat chronic anal fissure.
• Anal fistulas: Small tunnels form between the anal canal and surrounding organs, usually other parts of the bowel.
• Anal stenosis: the anal canal becomes abnormally narrowed either due to spasm of the anal sphincter or contraction of the resultant scar tissue.

Anal fissures can occur in children of any age, but are most common in toddlers. The infant may scream when defecating and have bright red blood in their feces.

A common problem of anal fissure in children is that they will often deliberately avoid defecating, which may cause hardening of feces, leading to repeated re-tearing of the old fissure and preventing healing.

Even once the fissure has healed, a child may still be fearful of defecating. To break this cycle, it is important to give the baby or child both suitable feces-softening medication and laxatives, under medical supervision, to ensure regular defecation. The correct dose varies from child to child and may be gradually adjusted so that the child consistently produces large, soft stools. 17

Good to know: Rarely, anal fissures in children could indicate sexual abuse, especially if other causes such as hard feces are not present. 6

• Anal ulcer
• Anal tear
• Fissure in Ano
• Rectal fissure

Q: Are there home remedies for anal fissure?
A: Yes, there are several measures for home treatment which may help. These include:

• Sitz baths or hip baths, which involve sitting in plain, non-soapy water after defecation to keep the area clean
• Sitting on a warm heating pad or warm water bottle is thought to promote healing as heat increases blood flow to the area

However, medical attention should always be sought where there is bleeding from the anus. It may indicate other conditions which must receive prompt treatment to ensure the best outcome, such as anal cancer.

Q: Anal fissure or herpes: how can one tell the difference?
A: It is possible to get herpes, a sexually transmitted infection, in the anal area. This can bring about what feels like a fissure around the anus and may be mistaken for one. Anal fissure causes burning pain and bleeding during defecation. Herpes causes blisters, itching and pain around the anus, but not especially while defecating, and lesions from herpes are unlikely to bleed.

Herpes may also cause flu-like symptoms and other associated problems such as pain with urination. Anal herpes normally has a history of sexual exposure to the herpes virus.

Read more about Herpes ».

Q: Are anal fissures dangerous?
A: No, anal fissures by themselves aren’t normally dangerous. However, they can be associated with more serious diseases., such as ulcerative colitis or Crohn’s disease. Also, cancer of the anus may mimic an anal fissure. Complications of an anal fissure may include: 15 16

• Chronic anal fissure: the tear fails to heal. Over time, this can cause extensive scar tissue at the site of the fissure.
• Incontinence: This may result from surgery to treat chronic anal fissure.
• Anal fistulas: Small tunnels form between the anal canal and surrounding organs, usually other parts of the bowel.
• Anal stenosis: the anal canal becomes abnormally narrowed either due to spasm of the anal sphincter or contraction of the resultant scar tissue.

Q: Are anal fissures painful?
A: Anal fissures usually cause pain during bowel movements that is often severe. It has been described as feeling like passing broken glass. Painkillers and efforts to soften stool, such as through medication or a high-fiber diet, can improve this symptom.

Q: Do anal fissures bleed?
A: Yes, most people with an anal fissure will notice a small amount of bright red blood either in their stools or on the toilet paper. More significant bleeding is indicative of symptoms being caused by another condition.

Q: How do you know if a fissure is healing?
A: Most anal fissures heal with home treatment after a few days or a weeks. These are known as acute anal fissures. Pain during bowel movements usually goes away within a couple of days after the start of treatment. If pain and blood in the stool persists longer than six weeks, then it is known as a chronic anal fissure, which may not heal with home treatment alone, and may need medical treatment. 18