Anal fissure symptoms: how to recognize an anal tear and what to do

The anal canal is a short canal at the end of the rectum, lined on the inside with thin skin that has many nerve endings. When hard stool or heavy straining tears this skin, a long, narrow wound forms. People often call it a tear; doctors call it an anal fissure. A fissure is usually located on the back wall of the anal canal, sometimes on the front wall.

Although a fissure is small, the pain is very strong. The reason is the sphincter (the ring-shaped muscle that closes the anal canal): as the wound hurts, the muscle tightens by reflex, the spasm reduces blood flow to the fissure, and the wound heals slowly. Afraid of the pain, a person puts off going to the toilet, the stool hardens and the next bowel movement tears the fissure open again. Breaking this vicious circle is the main goal of treatment. More about treatment options: anal fissure treatment.

The most common cause of a fissure is hard stool. The risk is higher with:

• constipation and heavy straining on the toilet;
• long-lasting diarrhea and frequent use of laxatives: liquid stool irritates the lining;
• pregnancy and childbirth, especially the first bowel movements after delivery;
• heavy lifting and straining while holding your breath during exercise;
• sitting on the toilet for a long time, including with your phone;
• mechanical injury, for example, from anal sex;
• certain diseases, such as Crohn's disease. In these cases, the fissure is often in an unusual location and needs further tests.

In women, years of difficult bowel movements are sometimes linked to a rectocele: the bowel doesn't empty completely, and the straining causes fissures and hemorrhoids.

You can often recognize an anal fissure by these signs:

• Sharp pain during a bowel movement. Patients describe it as feeling like being “cut with glass” or “torn.”
• Burning and throbbing that continue after a bowel movement. The pain lasts for minutes, sometimes a few hours. This is due to sphincter spasm.
• Bright red blood. There is usually only a small amount, seen as a streak on the toilet paper or on the stool.
• A feeling of spasm and tightness in the anal area.
• Itching and moisture. Discharge from the fissure irritates the surrounding skin.
• A small lump at the edge of the anus. This is a soft skin tag that forms next to a chronic fissure (a sentinel tag) and is often mistaken for a hemorrhoid.
• Fear of the toilet. Eating less and putting off bowel movements out of fear of pain makes constipation worse, and the fissure gets worse too.

Signs of an acute versus a chronic fissure

A fresh (acute) fissure has lasted less than 6–8 weeks, has soft edges and can heal with the right measures. A fissure that lasts longer than 6–8 weeks is considered chronic: the pain comes and goes, the fissure heals and reopens, its edges harden, and a sentinel tag or a small growth in the anal canal (an enlarged papilla) forms next to it. For a chronic fissure, home treatment is usually not enough.

Pain and blood from the anus make many people think of hemorrhoids first, but these symptoms occur in different conditions. The table below is only a rough guide:

The same person can have both a fissure and hemorrhoids. There are also other causes of bleeding: polyps, inflammatory bowel diseases and, rarely, tumors. Pain that is not related to bowel movements and gets worse at night or after sitting for a long time may have another cause, such as tailbone pain syndrome. So don't diagnose yourself. More: hemorrhoid treatment, anal abscess and anal fistula, causes of blood on toilet paper.

For a fresh fissure, the simple measures below often speed up healing. They matter for a chronic fissure too, but on their own they are usually not enough.

1. Soften your stool. Drink about 1.5–2 liters of fluid a day, mostly water (unless your doctor has told you otherwise). Eat vegetables, fruit, legumes and whole grains, and increase fiber gradually.
2. Take warm sitz baths. Sit in warm (not hot) water for 10–15 minutes 2–3 times a day, especially after a bowel movement. This relaxes the spasm and reduces pain. Plain warm water is enough: substances such as potassium permanganate can burn the skin if they are not diluted correctly.
3. Don't strain or linger on the toilet. Don't sit on the toilet for more than 5 minutes, and don't take your phone in with you. Don't hold it in when you need to go, either.
4. Protect the skin around the anus. After a bowel movement, rinse with warm water and pat dry with a soft towel. Scented wipes, alcohol-based solutions and lots of soap irritate the skin.
5. Put a small stool under your feet. When your knees are higher than your hips, the rectum empties more easily.

What to avoid:

• putting garlic, various oils or homemade mixtures on the anus: these can burn and irritate the lining;
• eating and drinking less out of fear of pain;
• masking the symptoms with painkillers and putting off seeing a doctor for months;
• buying and using “hemorrhoid suppositories” or creams from the pharmacy without a diagnosis.

If the pain and bleeding don't ease within 1–2 weeks with these measures, get examined. Detailed tips on preventing constipation: 5 golden rules against constipation.

Ointments, creams and suppositories play a supporting role in treating a fissure. They work better when combined with softening the stool and warm baths. Your doctor will tell you which medication you need after an examination, because the treatment for a fissure, hemorrhoids and an abscess is different.

Nitroglycerin cream

Nitroglycerin cream (a nitrate ointment) relaxes the internal sphincter and increases blood flow to the fissure, creating the conditions for the wound to heal. It is a prescription medication and is used as prescribed by a doctor, for the period indicated. The most common side effect is headache; dizziness sometimes occurs.

People with low blood pressure, people taking heart medications or medication for erectile problems (such as sildenafil), and pregnant and breastfeeding women should not use this cream without consulting a doctor. If headaches are severe, the doctor may choose a different type of sphincter-relaxing ointment, such as a diltiazem ointment.

Numbing ointments and suppositories

Numbing creams relieve pain for a short time but don't heal the fissure. Suppositories and combination ointments can ease inflammation and discomfort; your doctor chooses which form suits you based on where the fissure is and its condition. Hormone (steroid) creams should not be used on your own for a long time, because they can thin the skin.

In short, ointments and suppositories do help, but only after a correct diagnosis and as part of a comprehensive treatment. If the fissure has already become chronic, medications often reduce the pain for a while but don't close the wound.

If home measures and ointments don't close the fissure within 6–8 weeks, if the wound keeps reopening or if a sentinel tag has formed at its edge, the fissure is considered chronic and often needs surgery. The aim of surgery is to relieve the sphincter spasm or to remove the hardened tissue. We explain which method suits whom, how the operation goes and what recovery looks like on our anal fissure treatment and laser treatment pages.

See a proctologist if:

• you have seen blood on the toilet paper or in your stool for the first time, even if the pain has gone;
• the pain and bleeding don't ease within 1–2 weeks;
• the fissure keeps coming back or lasts more than 6–8 weeks;
• you can feel a lump at the edge of the anus;
• you are over 45–50 or close relatives have had bowel cancer: the cause of the bleeding should be investigated more thoroughly, with a colonoscopy if needed.

Don't wait, seek urgent care if:

• the area around the anus is swollen and red, the pain is throbbing and you have a fever: this may be a sign of an abscess;
• there is a lot of blood, the bleeding won't stop, or your stool has turned black;
• along with the blood loss, you feel dizzy and weak.

What happens at the examination?

Don't be afraid of the examination: the doctor doesn't rush and takes your pain into account. A fissure can often be seen at first glance, and if the pain is very strong, an examination with instruments can be postponed. We explain step by step what happens at the visit on our anal fissure treatment page.

Don't be embarrassed: an anal fissure is a very common and treatable problem. In Baku, female proctologist Dr. Ellada Manafova sees patients with these complaints at Qafqaz Hospital in a private, confidential setting.