Anal Fissure
An anal fissure is a small tear in the thin, moist tissue that lines the anus. The anus is the opening at the end of the digestive tract where stool exits the body. Common causes of an anal fissure include constipation and straining or passing hard or large stools during a bowel movement. Anal fissures typically cause pain and bleeding with bowel movements. You also may experience spasms in the ring of muscle at the end of your anus, called the anal sphincter.
Anal fissures are very common in young infants but can affect people of any age. Most anal fissures get better with simple treatments, such as eating more fiber or soaking in a warm-water bath. Some people with anal fissures may need medicine. Sometimes, surgery may be necessary.
Symptoms of an anal fissure include:
- Pain during bowel movements.
- Pain after bowel movements that can last up to several hours.
- Bright red blood on the stool or toilet paper after a bowel movement.
- A visible crack in the skin around the anus.
- A small lump or skin tag near the anal fissure.
When to see a doctor
See a healthcare professional if you have pain during bowel movements or notice blood on stools or toilet paper after a bowel movement.
Common causes of anal fissures include:
- Passing large or hard stools.
- Constipation and straining during bowel movements.
- Long-lasting diarrhea.
- Anal intercourse.
- Childbirth.
Less common causes of anal fissures include:
- Crohn’s disease or another inflammatory bowel disease.
- Anal cancer.
- HIV.
- Tuberculosis.
- Syphilis.
Factors that may increase the risk of developing an anal fissure include:
- Constipation. Straining during bowel movements and passing hard stools increase the risk of tearing.
- Childbirth. Anal fissures are more common in women after they give birth.
- Crohn’s disease. This inflammatory bowel disease causes chronic inflammation of the intestinal tract. This may make the lining of the anal canal more vulnerable to tearing.
- Anal intercourse.
- Age. Anal fissures can occur at any age, but are more common in infants and middle-aged adults.
Complications of an anal fissure may include:
- Failure to heal. An anal fissure that fails to heal within eight weeks is considered chronic and may need further treatment.
- Recurrence. Once you’ve experienced an anal fissure, you are prone to having another one.
- A tear that extends to surrounding muscles. An anal fissure may extend into the ring of muscle that holds the anus closed. This muscle is called the internal anal sphincter. If this happens, it makes it more difficult for the anal fissure to heal. An unhealed fissure may trigger a cycle of discomfort that may require medicines or surgery to ease the pain and to repair or remove the fissure.
You may be able to prevent an anal fissure by taking measures to prevent constipation or diarrhea. Eat high-fiber foods, drink fluids, and exercise regularly to keep from having to strain during bowel movements.
A healthcare professional will likely ask about medical history and perform a physical exam, including a gentle inspection of the anal region. Often the tear is visible. Usually, this exam is all that’s needed to diagnose an anal fissure.
A more recent, acute anal fissure looks like a fresh tear, somewhat like a paper cut. A long-lasting, also called chronic, anal fissure likely has a deeper tear. It also may have internal or external fleshy growths. A fissure is considered chronic if it lasts more than eight weeks.
The fissure’s location offers clues about its cause. A fissure that occurs on the side of the anal opening, rather than the back or front, is more likely to be a symptom of another condition, such as Crohn’s disease. A medical professional may recommend further testing to find out if there is an underlying condition. Tests may include:
- Anoscopy. An anoscope is a tubular device inserted into the anus to help see the rectum and anus.
- Flexible sigmoidoscopy. In this test, a thin, flexible tube with a tiny camera attached is inserted into the bottom portion of the colon. This test may be done for people younger than 45 who have no risk factors for intestinal diseases or colon cancer.
- Colonoscopy. This test involves inserting a flexible tube into the rectum to inspect the entire colon. Colonoscopy may be done for someone who:
- Is older than age 45.
- Has risk factors for colon cancer.
- Has symptoms of other conditions.
- Has other symptoms, such as stomach pain or diarrhea.
Anal fissures often heal within a few weeks with appropriate home treatment. Take steps to keep the stool soft, such as increasing your intake of fiber and fluids. Soak in warm water for 10 to 20 minutes several times a day, especially after bowel movements. This can help relax the sphincter and promote healing. If symptoms persist, you’ll likely need further treatment.
Nonsurgical treatments
A healthcare professional may recommend the following:
- Externally applied nitroglycerin (Rectiv) can help increase blood flow to the fissure and promote healing. It also can help relax the anal sphincter. Nitroglycerin is generally considered the treatment of choice when other conservative measures fail. Side effects may include headache, which can be severe.
- Topical anesthetic creams such as lidocaine (Xylocaine) may help relieve pain.
- OnabotulinumtoxinA (Botox) injection paralyzes the anal sphincter muscle and relaxes spasms.
- Blood pressure medicines, such as nifedipine or diltiazem, help relax the anal sphincter. These medicines are generally applied to the skin but also can be taken by mouth. However, when taken by mouth, their side effects can be greater. These medicines may be used when nitroglycerin is not effective or causes serious side effects.
Surgery
If you have a chronic anal fissure that is resistant to other treatments, or if your symptoms are severe, surgery may be recommended. Surgeons usually perform a procedure called lateral internal sphincterotomy (LIS). LIS involves cutting a small part of the anal sphincter muscle. This technique may help promote healing and reduce spasm and pain.
Studies show that surgery is much more effective than any medical treatment for chronic fissure. However, surgery has a small risk of causing incontinence.
References
- Kellerman RD, et al. Hemorrhoids, anal fissure, and anorectal abscess and fistula. In: Conn’s Current Therapy 2022. Elsevier; 2022. https://www.clinicalkey.com. Accessed Nov. 10, 2022.
- Jin JZ, et al. A systematic review and network meta-analysis comparing treatments for anal fissure. Surgery. 2022; doi:10.1016/j.surg.2021.11.030.
- Gilani A, et al. Chronic anal fissure in adults. The BMJ. 2022; doi:10.1136/bmj-2021-066834.
- Townsend CM Jr, et al. Anus. In: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 21st ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed Nov. 10, 2022.
- Anal fissure. American Society of Colon and Rectal Surgeons. https://fascrs.org/patients/diseases-and-conditions/a-z/anal-fissure-expanded-information. Accessed Nov. 9, 2022.
- Stewart DB. Anal fissure: Clinical manifestations, diagnosis, prevention. https://www.uptodate.com/contents/search. Accessed Nov. 10, 2022.
- Ami TR. AllScripts EPSi. Mayo Clinic. Oct. 3, 2022.
- Colorectal cancer: Screen. U.S. Preventive Services Task Force. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening. Accessed Nov. 21, 2022.
- Medical review (expert opinion). Mayo Clinic. Nov. 20, 2022.
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