The anus is the opening at the bottom where feces come out of the body. When a tear or crack occurs in the skin of the anus, it is called an anal fissure.
Anal fissures can cause bleeding and pain. Bleeding may be bright red and appear on the toilet or toilet paper after wiping. Fissures can cause pain, ranging from mild to severe, during and after a bowel movement.
Anal fissures can be acute or chronic. The more common acute fissures can be cured with at-home treatment. Uncommon chronic anal fissures are a lingering problem. Chronic fissures may require more intensive treatment by a health care professional, which may include surgery.
This article includes a description of anal fissures and methods for their diagnosis and treatment.
Types of Anal Fissures
Anal fissures can be divided into acute and chronic.
acute anal fissure
An anal fissure is considered acute when symptoms improve with treatment within about six weeks. Anal fissures may improve by treating any underlying cause, such as constipation (large, hard stools).
chronic anal fissure
A chronic anal fissure is an anal fissure that lasts more than six weeks. In chronic fissures, more conservative home treatments have not worked. In this case, injections or surgery may be needed to cure it.
anal fissure symptoms
Symptoms of an anal fissure may include:
- rectal bleeding
- pain in the anal area during bowel movements
- Pain in the anal area that persists for several hours after a bowel movement
- tenderness or discomfort in the anal area
There are several potential causes and risk factors for developing an anal fissure. These include:
- Constipation: Hardness caused by constipation is a risk factor.
- Chronic diarrhea: This is recurring loose or frequent stools.
- Sexually Transmitted Infections (STIs): including syphilis and herpes, spread during sexual contact.
- Inflammatory bowel disease (IBD): These conditions show inflammation of the digestive tract and may produce chronic diarrhea.
- Human Immunodeficiency Virus (HIV): This virus suppresses the immune system and spreads through body fluids, including through sex.
- anal cancer
- anal surgery
- anal sex
- Tuberculosis: This bacterial infection rarely occurs in the anal area and causes pain or cracks.
Anal fissures are common in babies and children, but can happen to anyone at any stage of life. In infants and children, the cause is usually through large, hard stools.
The diagnosis of an anal fissure is usually made by a health care professional after discussing the symptoms and performing a physical examination. A physical exam means looking at the anal area to see if there are other causes of pain or bleeding.
Tests that look inside the anal canal are usually not used because they can cause more discomfort. Observing the area should be as gentle and brief as possible.
blood in stool
Blood in the stool, on toilet paper after wiping, or in the toilet is never normal. Common causes of blood include hemorrhoids (swollen and inflamed veins in the anus or rectum) and fissures, but it’s important to rule out other, more serious causes. Even if blood has been seen in stool before, this should be discussed with a healthcare professional.
Treatment usually starts with conservative measures, and if the fissure does not improve, more invasive treatments may be tried.
Taking a sitz bath, soaking your buttocks in shallow warm water, can relieve discomfort. This can be done by placing a shallow plastic tub (also called a bidet) under the toilet seat, or sitting in a clean tub with minimal filling.
A healthcare professional may recommend adding Epsom salts (magnesium sulfate salts commonly used for soaking) to the water. A sitz bath can be used for about 20 minutes at a time, several times a day.
Instead of using paper wipes, using baby wipes, a squeeze bottle of water, or a bidet (a toilet attachment or separate bathroom fixture that sprays the anal area with water) can also reduce pain.
If the cracks are caused by difficult bowel movements, it may be helpful to make stools that are softer and easier to pass. Drinking plenty of water, eating foods with fiber, or using fiber supplements, stool softeners, or laxatives may help. How much fiber to use and which fiber supplement to use should be discussed with a healthcare professional.
It’s important for kids to make sure they don’t pull up on the stool because going to the bathroom can be a pain. Holding on to a stool can worsen constipation, which can lead to cracks.
Some medications may be applied directly to the fissure to help relieve pain and/or promote healing.
Apply nitroglycerin rectal ointment directly to the anus with clean or gloved fingers or an applicator as directed by your healthcare provider. This medication helps relax the muscles of the anus, thereby reducing pain. For adults, it may be used twice a day.
Topical lidocaine is another medication that may help relieve painful bowel movements. Apply this cream with clean or gloved fingers or applicator. It can be used twice a day.
Calcium channel blockers are drugs that treat blood pressure. They also relax the anal muscles, preventing cramps and discomfort. They can be administered orally or topically (applied directly in the field). Using the topical form can help prevent side effects.
Injections of botulinum toxin (botulinum toxin type A) can be used for anal fissures that do not improve with minimally invasive treatments. Botulinum toxin is injected into the muscle of the anal sphincter by a healthcare provider. This medication helps prevent spasms of the anal muscles, which can be painful.
Procedures such as anal flap (transferring a flap of living skin tissue over the anal fissure), fissure resection (removal of the anal fissure), or sphincterotomy may be used for anal fissures that cannot be cured by other measures.
The most common procedure is a lateral sphincterotomy. This involves cutting the muscles of the anal sphincter, which helps it heal cleanly. Surgery is effective for treating fissures, but any surgery has risks. Surgery and medication may be more effective in the long run.
Most cases of anal fissures improve with home measures, such as avoiding constipation and/or some medications for pain and cramping.
Some people develop chronic fissures that may require surgery. However, surgery has a good chance of healing the fissure. To prevent chronic, recurring illness, it is important to maintain self-care practices at home.
Anal fissures are painful and disturbing. The anal sphincter takes time to heal because it is often used for bowel movements. Seeking care early after symptoms and following your healthcare provider’s advice can help. Some people may prefer to ask for a referral to a digestive specialist, such as a gastroenterologist.
Dealing with digestive issues and describing symptoms can be awkward. It’s important to remember that healthcare professionals are always helping their patients with digestive disorders. Asking any unclear questions will help keep you on track.
An anal fissure is a crack or tear in the anal canal. Treatment can include controlling constipation, applying topical medications, and in some cases, surgery. Most people do well with conservative measures and the fissure will not recur.
Anal fissures can be painful, and it can be shocking to see blood in or on the stool. However, it’s important to remember that anal fissures are a common problem that most people do well with conservative treatment.
Fissures may heal and not recur. However, if the condition does become chronic or recurs after treatment, surgical options work well and can provide relief if needed.