Anal Fissure: A Treatable Condition
What is an anal fissure?
Anal fissures are small tears in the thin tissue (mucosa) that lines the anus. (The anus is the opening at the end of your gastrointestinal tract). These tears can be painful and make you bleed.
Sometimes, fissures rip slowly over time. Other times, they happen all of a sudden, from having to push a large stool or from childbirth.
Anal fissures cause pain, bleeding when passing stools, and spasms of the muscle in the anus. The tears usually heal on their own within a few days.
Most common symptoms
The most common symptoms of an anal fissure are pain, bleeding when passing stool, and muscle spasms in the anus (called tenesmus).
Pain is usually worse while passing stool. But it can last for several hours after you have a bowel movement.
You’ll see blood in the toilet bowl, covering your stool, or on toilet paper mixed in with your stool.
Tenesmus spasms make you feel like you need to have a bowel movement even when you don't.
- Pain with or following bowel movements.
- Bleeding associated with bowel movements that is seen on the toilet paper, in the bowl, on the stool, or mixed in the stool.
Other symptoms you may have
If you get fissures regularly, you may feel an extra piece of skin (a skin tag) in the area of your anus.
Causes of anal fissure
Fissures can happen spontaneously—they do not necessarily indicate any underlying chronic disease. But if they don’t heal on their own, it may be a sign of an underlying disease (i.e. inflammatory bowel disease). It may require medication or surgery, as well as further workup. —Dr. Shria Kumar
Anal fissures can tear for many different reasons. Usually it’s from physical damage to the anus, most often from constipation (particularly long standing constipation). Other causes can include chronic diarrhea, trauma (such as receptive anal sex), or during childbirth (when the vagina and anus can tear).
Certain chronic diseases or conditions can also increase your risk of getting one, such as inflammatory bowel disease, cancer, and sexually transmitted diseases, according to the National Institutes of Health. They may weaken the surrounding tissue, making them more at risk of fissures.
You’re more likely to get fissures if you have:
Treatments for anal fissures
An important question to ask your doctor: What risk factors predisposed me to getting this fissure? —Dr. Kumar
If you feel pain or see blood whenever you have a bowel movement, see your primary care doctor. Your doctor will ask you a series of questions to get a better sense of your risk factors. They will perform a physical exam, including a rectal exam. They may also order blood tests to rule out an infection, and may send you to a general or colorectal surgeon or a gastroenterologist (a doctor who specializes in the digestive tract).
If you’re bleeding a lot and start to feel lightheaded or dizzy, go to the ER.
If the reason for a fissure is regular constipation, your doctor may have you start with home remedies. Sitz baths (sitting in warm shallow water) can be soothing. You can also try stool softeners, eating more fiber, and drinking more water.
Fissures usually heal on their own, without the need for treatment. If the pain is severe, your doctor can prescribe topical numbing medications that you apply to your skin. Other topical medications used for fissures include externally applied nitroglycerin, which increase blood flow to the fissure to help it heal.
- Nitrate ointment: This helps raise blood flow to the anal canal and sphincter, which helps fissures get better faster.
- Calcium channel blockers: These are blood pressure-lowering medications. Some of the topical ones can treat anal fissures, too.
- Botox injections: Injecting botulinum toxin type A (Botox) into the sphincter may relieve pain and encourage healing.
For cases of chronic anal fissures that do not heal on their own, your doctor may recommend surgery. This is rare.
Prior to surgery, your doctor might also want to use a scope to take a closer look at the anal tissue to help diagnose the cause of the fissure. If your doctor suspects anal cancer, they will take a biopsy.
If surgery is suggested, the surgeon will cut a portion of the anal muscle to relax it (lateral internal sphincterotomy). This will reduce pain and help healing.
- If the fissure doesn't heal on its own within 1 to 2 weeks, make an appointment to see your doctor.
- If you have surgery, follow up with your surgeon to make sure you’re healing well.
- Drink lots of water and take a fiber supplement to prevent constipation. Make sure you’re having soft daily bowel movements
- If your fissure is from an STI, talk with your doctor about how to best take care of the infection.
- If your fissure is from inflammatory bowel disease or anal cancer, talk to your gastroenterologist or general surgeon about the best treatment.
How do I know if I have a hemorrhoid or a fissure?
In severe cases, blood pressure medications can also be used to provide blood flow that can help with healing. —Dr. Kumar
Both anal fissures and hemorrhoids cause pain and bleeding. But there is a big difference. An anal fissure is a tear of tissue. Hemorrhoids are a group of swollen veins inside the anal canal or at the anal opening.
Hemorrhoids tend to be painful or bleed, but not both. Fissures, on the other hand, tend to bleed and be painful. A doctor can see and feel the difference during a rectal exam.
Lower your chances of getting anal fissure by:
- Drinking a lot of water and eating a lot of fiber to keep from getting constipated.
- If you have penetrative anal sex, use plenty of lubricant.
- Use a condom to prevent getting an STD. If you think you have an STD, get tested. If positive, tell your doctor.
- Talking to your doctor if you have a family history of inflammatory bowel disease or you have chronic diarrhea, constipation, or bloody stool.
Sourav Bose is a postdoctoral research fellow at the Center for Fetal Research in the Department of Surgery at the Children’s Hospital of Philadelphia and is a general surgery resident at the Brigham and Women’s Hospital affiliated with Harvard Medical School.
His current clinical investigation is in care programs for children with congenital anomalies and he is particularly interested in understanding how organizational structure and management influence patient outcomes and access to advanced precision care. He is also actively engaged in translational work investigating the efficacy of in utero gene therapy for congenital metabolic diseases. Previously, Sourav conducted and published research on pricing of healthcare services in Guatemala and Mongolia and on pediatric trauma outcomes.
Sourav received a BSc Economics from the Wharton School and a BA Biology from the School of Arts and Sciences through the Roy & Diana Vagelos Program in Life Sciences and Management at the University of Pennsylvania. He subsequently was awarded the Thouron Fellowship to pursue an MSc Public Health at the London School of Hygiene and Tropical Medicine. His master’s thesis evaluated the organizational and human resources investments necessary to conduct global clinical trials focusing on the Crash-2 investigative group. He returned to Penn where he received his MD from the Perelman School of Medicine and his MBA in Healthcare Management from the Wharton School.