Anal Fissure
Anal fissures cause real pain. The good news: most heal well with the right care.
Most acute fissures heal with simple conservative treatment. For persistent cases, modern options offer effective relief without major surgery.
An anal fissure is a small tear in the lining of the anal canal. Fissures are one of the most common causes of severe anal pain, especially with bowel movements. Most are caused by the mechanical stress of passing large or hard stools, but persistent or recurring fissures sometimes point to underlying conditions that deserve evaluation.
Dealing with pain during bowel movements or bright red bleeding? Book a consultation.
Book a consultation
Why Anal Fissures Hurt So Much (And Won't Heal)
Fissures are uniquely painful because of a self-reinforcing cycle involving the anal sphincter muscle.
The fissure pain cycle
1
Tear occurs. Usually from passing a hard or large stool.
2
Pain triggers muscle spasm. The internal sphincter tightens involuntarily.
3
Spasm reduces blood flow to the fissure, which slows or prevents healing.
4
The fissure persists and re-tears with each bowel movement, restarting the cycle.
Breaking this cycle is the core principle behind most fissure treatments. Softening stools reduces new trauma, and relaxing the sphincter muscle restores blood flow to allow healing.
Acute vs Chronic Fissures
Fissures are categorized by how long they've been present. The distinction matters because it shapes treatment.
Acute fissure
Duration: Less than 6 weeks.
Appearance: A fresh, shallow tear in the skin.
Outlook: The majority heal with conservative care alone: fiber, hydration, sitz baths, and stool softeners.
Chronic fissure
Duration: More than 6 weeks, or recurring.
Appearance: Often has characteristic features like a skin tag at the outer edge, a small papilla at the inner edge, and visible muscle fibers in the base.
Outlook: Usually needs topical medications, Botox injection, or surgical treatment to heal.
Common Causes
Most fissures are mechanical, caused by the passage of hard or large stools that stretch the anal canal beyond what the tissue can handle. But other factors contribute too.
Constipation and straining
The most common cause. Passing hard or large stools stretches the anal tissue past its limit.
Chronic diarrhea
Frequent bowel movements and acidic stool can irritate and damage the anal lining.
Childbirth
The physical stress of vaginal delivery can cause fissures, sometimes alongside other postpartum pelvic floor issues.
Infancy
Anal fissures are notably common in infants due to constipation from diet changes and still-developing bowel habits.
Inflammatory bowel disease
Crohn's disease and ulcerative colitis can cause fissures that are often in atypical locations and harder to heal.
Infections
Sexually transmitted infections, tuberculosis, and HIV are less common causes, typically associated with atypical or persistent fissures.
Anal trauma
Any injury to the anal area, including from anal intercourse or medical procedures, can create a fissure.
Rarely, cancer
Anal cancer can occasionally present as a fissure that doesn't heal. A persistent, atypical fissure warrants thorough evaluation.
Common Symptoms
Fissures may not be easily visible because of their location, but the symptoms are usually recognizable.
Sharp pain during bowel movements, often lasting minutes to hours afterward
Bright red blood on toilet paper or coating the stool
Burning or itching sensations
A visible tear or crack in the skin at the anus
A small skin tag near the fissure (in chronic cases)
Constipation, sometimes worsened by fear of painful bowel movements
Unpleasant-smelling discharge
Persistent discomfort or aching after bowel movements
When to get evaluated: Most fissures heal within a few weeks of conservative care. If pain persists beyond 6 weeks, symptoms don't improve with home care, the fissure is in an unusual location, or you have any concerning changes, it's time for a professional evaluation to identify the right treatment and rule out underlying causes.
How Anal Fissures Are Diagnosed
During your consultation, Dr. Chung will review your symptoms and medical history, and perform a gentle physical examination. Most fissures can be identified on visual inspection. In some cases, a very gentle anoscopy may be used, though if pain is severe the exam may be limited until initial treatment has eased symptoms. If there's any concern about underlying conditions, additional testing like colonoscopy may be recommended.
Treatment Options
Treatment follows a stepwise approach, starting with the simplest options and escalating as needed. Most fissures never need more than the first step.
First line
Conservative care
Fiber supplementation, adequate hydration, stool softeners, and warm sitz baths form the foundation of fissure treatment. Over-the-counter topical creams and lidocaine-containing products can ease pain during healing. For acute fissures, this approach heals the majority of cases within a few weeks.
Next step
Topical medications
When conservative care isn't enough, prescription topical medications can break the sphincter spasm cycle. Nitroglycerin ointment and calcium channel blocker creams (such as nifedipine or diltiazem) relax the internal sphincter muscle, restoring blood flow and allowing the fissure to heal. Applied two to three times daily for several weeks.
For stubborn cases
Botox injection
Botulinum toxin injected into the internal sphincter muscle temporarily relaxes the spasm, which gives the fissure time to heal. Effects last about two to three months, often long enough for complete healing. A good option for chronic fissures that haven't responded to topical treatment, and an alternative to surgery for patients who want to avoid it.
For chronic fissures
Lateral internal sphincterotomy
The gold-standard surgical treatment for chronic fissures. A small, precise cut is made in the internal sphincter muscle to permanently reduce the spasm and allow healing. Success rates exceed 90 percent for chronic fissures. Recovery is typically quick, with most patients returning to normal activities within one to two weeks.
Prevention
Once a fissure has healed, these habits significantly reduce the chance of another one.
✓Eat a fiber-rich diet (25 to 30 grams daily) with fruits, vegetables, and whole grains.
✓Stay well hydrated, especially when increasing fiber intake.
✓Don't strain during bowel movements. Give yourself enough time.
✓Go when you feel the urge. Holding it can lead to harder, more difficult stools.
✓Take stool softeners when needed, especially during travel or dietary changes.
✓Exercise regularly to support healthy bowel function.
✓Address chronic diarrhea or constipation rather than working around it.
Recovery and Aftercare
Recovery depends on the treatment. Conservative care and topical medications require no downtime but several weeks of consistent use. Botox injection is done in the office with immediate return to daily activities. Surgical treatment with lateral internal sphincterotomy typically involves minimal downtime, with most patients resuming normal activities within one to two weeks. Dr. Chung provides detailed aftercare instructions covering wound care, activity guidelines, and bathroom habits to support smooth healing.
Get real relief from fissure pain
If you're dealing with painful bowel movements or a fissure that isn't healing, Dr. Chung can walk you through the options and help you find the right treatment for your specific situation.
Book a consultation
Call (714) 988-8690
