Anal fissure treatment: symptoms, causes and methods

An anal fissure is a tear in the thin, nerve-rich skin of the anal canal, caused by hard stool or heavy straining. What turns it into a long-lasting problem is sphincter spasm (the sphincter is the ring-shaped muscle that closes the anal canal): in response to pain the muscle tightens, less blood reaches the wound, and every new bowel movement opens the fissure again.

That is why treatment has three goals: soften the stool, relax the spasm and give the wound a chance to heal. With an acute fissure this can often be done with medication and a good routine. With a chronic fissure, a short operation is needed to relieve the spasm or remove the hardened tissue. We explain why a fissure hurts so much and how to recognize it in more detail in our article on the symptoms of an anal fissure.

With an anal fissure, the pain starts with a bowel movement: a cutting pain as stool passes, which can last for hours afterward. A little bright red blood on the paper, a feeling of tightness in the anus, itching, and putting off the toilet out of fear of pain are also typical. When a fissure has been there for a long time, a small fold of skin, a sentinel tag, can form at its edge.

These symptoms can be confused with other conditions. Bleeding also occurs with hemorrhoids (piles), polyps and inflammatory bowel disease. Constant, throbbing pain and swelling, on the other hand, can be a sign of an anal abscess (paraproctitis). That is why only an examination can confirm the diagnosis. We describe the symptoms in detail, how to tell a fissure from hemorrhoids and what to do at home in our article on the symptoms of an anal fissure.

The main cause of a fissure is hard stool and straining, so treatment always goes together with treating constipation. Long-lasting diarrhea, pregnancy and childbirth, straining while lifting heavy objects, sitting on the toilet for a long time and mechanical injury can also cause a fissure.

With a rectocele (a bulging of the rectum toward the vagina), stool does not empty completely and a woman has to strain for years. This is another possible cause of a fissure. If the fissure is not in the typical spot, or if there are several, we carry out additional tests to rule out inflammatory bowel diseases such as Crohn's disease.

With a chronic fissure, medication is often not enough, because the hardened edges and constant spasm keep the wound from closing. That is why seeing a doctor early makes treatment simpler.

An anal fissure itself is not an emergency. But in these situations, do not wait. Seek care right away:

• increasing swelling, redness, constant throbbing pain and fever around the anus: this may be a sign of an anal abscess (paraproctitis);
• bleeding that does not stop or comes with clots, or black stools;
• dizziness, weakness or a racing heart along with bleeding.

A fissure left untreated for a long time can, in rare cases, become infected and turn into an abscess and an anal fistula, and over the years it can scar and narrow the anal canal. Stools that stay thin, “pencil-like,” for a long time always need to be examined.

Many patients are more afraid of the examination than of the fissure itself. Try not to worry: the examination is short and is done carefully, taking your pain into account.

1. Conversation. We ask about the nature of the pain, bleeding, the shape of your stool, childbirths and the medications you take.
2. Inspection. You lie on your side with your knees drawn toward your abdomen. The fissure can often be seen by gently parting the edges of the anus, and the diagnosis is usually made at this stage.
3. Finger examination and anoscopy (a look into the anal canal with a short, thin instrument). If the pain is severe, this step is done gently with a numbing gel, or postponed until the pain eases.
4. Additional tests. If another cause of bleeding is possible, if you are over 45–50, or if colon cancer runs in your family, we may recommend a colonoscopy.

After the examination, we explain in detail what type of fissure you have and which treatment plan suits you.

Treatment depends on whether the fissure is acute or chronic, the condition of the sphincter and any accompanying problems (hemorrhoids, rectocele, constipation). Not every complaint means surgery.

Conservative treatment

With an acute fissure, the main aim is to soften the stool, reduce the spasm and create the conditions for the wound to heal:

• Diet and water. High-fiber foods (vegetables, fruit, whole grains) and enough water during the day soften the stool. If needed, we prescribe a stool softener.
• Warm sitz baths. They ease the pain and relax the tight muscle; this is the first step for acute pain.
• Ointments prescribed by a doctor. An ointment that relaxes the sphincter (for example, a nitroglycerin cream) improves blood flow to the wound and helps it heal. Because of possible side effects, such medications are used only when prescribed by a doctor. If the pain is severe, a numbing cream may also be prescribed for a short time. We explain which ointment helps and when in a separate article.
• Suppositories and creams alone are not enough. The result comes from diet, baths and medication working together. Suppositories bought from the pharmacy on your own can mask the symptoms and waste time.

Conservative treatment usually lasts 6–8 weeks, and you come in for a follow-up examination during this time. If the fissure does not heal, we plan the next step together. You can read about when medication is chosen and when surgery is chosen on the surgical and conservative treatment page.

Surgical and minimally invasive methods

Surgery is usually offered in these cases: the fissure has lasted more than 6–8 weeks, has not responded to conservative treatment, has hardened edges, has developed a sentinel tag, or keeps coming back. The methods we use:

• Lateral internal sphincterotomy. A small part of the internal sphincter is cut from the side (using an open or closed technique). The spasm goes away, blood flow is restored and the fissure begins to heal. A small number of patients may have mild difficulty holding gas or loose stool, which is often temporary. For this reason, in patients whose sphincter was injured during childbirth or is weak, we prefer methods that preserve the sphincter.
• Fissurectomy (removal of the fissure). The hardened, non-healing edges of the fissure are removed, turning a chronic fissure into a fresh wound. With the right diet and treatment, the wound then heals. If there is a sentinel tag or an enlarged papilla, it is removed at the same time.
• Flap repair (anoplasty). After the fissure is removed, the wound is covered with a small flap made from healthy skin nearby. This method does not touch the sphincter.
• Laser. The chronic tissue of the fissure is cleaned with laser energy, and the incision is minimal. We explain who laser suits on the laser treatment page.

The operation usually takes about 15 minutes and is done as an outpatient procedure, meaning that in most cases you go home the same day. The type of anesthesia is decided according to the method chosen and your condition, and it is explained in detail before the operation. If you also have hemorrhoids or a rectocele, they can be treated together under one anesthetic with combined (“bouquet”) surgery (several procedures in one session). The exact duration is given after the examination.

The exact timeline is given after the examination. The moment patients fear most is the first bowel movement. Because the spasm is relieved, the sharp pain that lasted for hours before surgery usually eases quickly. We agree on when you can return to sex together at the follow-up visit.

These rules matter even after the fissure has healed, because the main reason it comes back is hard stool and straining again:

1. Keep your stool soft. Increase fiber gradually and drink enough fluids during the day.
2. Don't stay on the toilet. 5 minutes is enough: sit without your phone, and if nothing comes, get up and try again a little later.
3. Don't hold it in. The “I'll go when I get home” habit dries out and hardens the stool.
4. Change your position. A small footstool under your feet at the toilet makes it easier for the rectum to empty.
5. Protect your skin and don't ignore diarrhea. Use warm water instead of scented wipes and soap, and treat constipation and diarrhea on time.

You can find an explanation of each rule in the article 5 golden rules against constipation.

Our patient had suffered from an anal fissure and hemorrhoids for five years, with sharp pain and bleeding after every bowel movement. Because they had put off seeing a doctor for years, the anal canal had also narrowed. After the examination, the fissure and the hemorrhoids were treated in one operation, and the patient was relieved of the pain that had bothered her for so many years. Every patient's situation is individual.