An anal fissure is a small tear or cut in the tissue lining the anus, causing symptoms like pain, discomfort, small amounts of bleeding, and burning with defecation (having a bowel movement).

Anal fissures are usually caused by bowel movements that are very hard and dry, constipation, severe diarrhea, anal intercourse, or anal surgery.

Treatment of an anal fissure may be done by a proctologist, gastroenterologist, or primary care provider, and typically involves the use of ointments, good hygiene practices, diet changes, and the use of laxatives and analgesics as needed. Surgery may be indicated in more complex cases.

Common symptoms

The main symptoms of an anal fissure include:

Anal pain that worsens when having a bowel movement;
Burning and stinging with a bowel movement or during urination;
Bright red blood noticed in the stool or on the toilet paper;
Anal itching.

You may also feel a small cut in the skin around the anus when cleaning the area, which will be visible to a doctor during a physical exam.

Symptom quiz

To determine the likelihood of having an anal fissure, check off your symptoms using the following quiz:

1. External anal pain
2. Blood when wiping
3. Blood in the stool
4. Anal burning, especially after a bowel movement or urinating
5. Itchy anus

This symptom quiz should only be used as a tool and should not be used in place of a consultation with a healthcare provider. Make sure to contact your doctor or primary care provider if you think you might have an anal fissure.

Confirming the diagnosis

The diagnosis of an anal fissure is usually made by a proctologist, gastroenterologist, or primary care provider based on evaluation of symptoms, medical history (including any history of anal surgery), and a physical exam. Your provider will also ask you questions such as how often you have a bowel movement.

In some cases, other exams like anoscopy or colonoscopy may be indicated, especially if the fissure is small or in a location that is difficult to visualize.

Main types

The main types of anal fissures are:

1. Acute anal fissure

An acute anal fissure is characterized by sudden onset of symptoms that last for 6-8 weeks and usually improve with conservative treatment.

This type of anal fissure typically causes pain that is worse during a bowel movement and might last for hours. Anal bleeding is also common.

2. Chronic anal fissure

A chronic anal fissure is an anal fissure lasting for longer than 8 weeks. It is typically deeper than an acute anal fissure and does not resolve with first line treatment.

Treatment with ointments, Botox injections, or surgery is typically indicated in these cases.

3. Primary anal fissure

A primary anal fissure is caused by direct trauma to the anal tissues, such as from hard, dry stool or chronic constipation, for example.

See constipation relief.

4. Secondary anal fissure

A secondary anal fissure develops due to other health conditions, such as inflammatory bowel disease or sexually transmitted infections.

Possible causes

The main causes of an anal fissure include:

Straining to have a bowel movement;
Chronic constipation or diarrhea;
Ulcerative colitis and Crohn's disease;
Anal intercourse without adequate lubrication;
History of anal surgery;
Anal cancer.

Anal fissures can also develop due to childbirth or from sexually transmitted infections like genital herpes, HIV, syphilis, HPV, chlamydia, or gonorrhea.

Treatment options

Treatment for an anal fissure should be done in consultation with a proctologist, gastroenterologist, or primary care provider and will depend on the size of the fissure as well as the severity of symptoms.

The most common treatments for anal fissure include:

1. Sitz baths

Performing sitz baths using warm water for 5 to 20 minutes, primarily after a bowel movement, may be advised by your provider to help reduce pain and relieve symptoms like burning and stinging.

2. Good hygiene

Good hygiene practices are important to prevent an anal fissure from becoming infected, which can interfere with healing.

It is recommended to clean the anal region well after a bowel movement, whenever possible, using a gentle soap and water. Pat the area dry using a towel that is clean, dry, and soft.

Avoid using toilet paper or wet wipes as these can irritate the area, making symptoms worse.

3. Dietary changes

Diet plays a very important role in the treatment of anal fissures, helping to soften the stool and relieve constipation.

A well-balanced diet high in fiber and drinking lots of water are recommended to help make it easier to have a bowel movement and prevent the anal fissure from reopening.

4. Avoiding straining

It is important to avoid straining when having a bowel movement. Avoid spending a long time on the toilet and make sure not to force a bowel movement.

This is because straining increases pressure in the anal region, leading to a worsening of symptoms and making healing more difficult.

5. Medicated ointments

Ointments that may be prescribed for treatment of an anal fissure include:

Antiseptics and anti-inflammatories, such as cinchocaine or lidocaine, to help relieve pain, itching, and burning;
Calcium channel blockers, such as diltiazem, to help relax the anal sphincter, improve blood flow to the area, and promote healing;
Vasodilators, such as isosorbide dinitratecomo, that help improve blood flow to the area of the fissure and facilitate healing.

Medicated ointments are generally indicated for the treatment of anal fissures when symptoms are very severe and cause intense discomfort when having a bowel movement. They should only be used as directed by a doctor.

These treatments can help reduce pain and inflammation and accelerate healing.

6. Other medications

Medications like acetaminophen and ibuprofen may be recommended by your healthcare provider in the case of severe pain associated with an anal fissure.

Your provider may also prescribe the use of stool softeners to help avoid straining and make it easier to have a bowel movement.

Antibiotics may be prescribed if the anal fissure becomes infected.

7. Botox injections

Botox injections can be done by a doctor to relax the muscles around the anus and help relieve severe pain.

This type of treatment is usually indicated in cases of chronic anal fissures that do not improve with other more conservative measures.

8. Surgery

Surgery may be indicated for the treatment of chronic recurring anal fissures when other treatment options are ineffective at relieving symptoms and promoting healing.

This surgery can be performed by making a small cut in the muscle of the anal sphincter, a procedure known as a lateral internal sphincterotomy, to reduce pain and allow for healing.

Another surgery than can be done is called a fissurectomy, in which the surgeon removes the fissure and some of the healthy tissue around it.

Self-care measures

Your healthcare provider may recommend certain self-care measures for the treatment of anal fissures, including:

First line therapies such as sitz baths, good hygiene practices, and eating a high-fiber diet;
Drinking enough water throughout the day to help make bowel movements softer and easier to pass;
Avoiding straining with bowel movements and sitting too long on the toilet;
Regular physical activity to stimulate gut mobility.

Follow up with your healthcare provider if symptoms fail to improve with these measures alone. Other treatment options may be indicated for relief of symptoms.