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.

Main symptoms

• 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

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:

• Constipation
• Regular diarrhea
• Receptive anal intercourse
• Certain sexually transmitted infections, such as herpes or syphilis
• Anal cancer
• Inflammatory bowel disease, such as Crohn’s disease and ulcerative colitis

Treatments for anal fissures

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.

Medication

• 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.

Surgery

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.

Follow up

• 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?

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.

Preventative tips

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.