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Anal Fissure – Causes, Symptoms & Treatment

An anal fissure is a small tear in the lining of the anal canal. It causes intense pain during bowel movements and can be either acute or chronic.

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Things worth knowing about "Anal Fissure"

An anal fissure is a small tear in the lining of the anal canal. It causes intense pain during bowel movements and can be either acute or chronic.

What Is an Anal Fissure?

An anal fissure (Latin: Fissura ani) is a small, painful tear in the mucous membrane or skin lining the anal canal – the final section of the large intestine leading to the anus. It is a common proctological condition that can affect people of all ages, though it is particularly prevalent in young adults and infants.

Two forms are distinguished: the acute anal fissure, which has been present for a short time and responds well to conservative treatment, and the chronic anal fissure, which persists for more than six weeks and typically shows characteristic tissue changes such as a sentinel skin tag or a hypertrophied anal papilla.

Causes

The most common cause of an anal fissure is mechanical overstretching of the anal canal. Typical triggers include:

Constipation with hard, dry stools
Persistent diarrhea, which irritates the sensitive mucous membrane
Straining during bowel movements
Elevated internal sphincter tone (chronic contraction of the internal anal sphincter), which reduces blood flow and impairs healing
Childbirth – vaginal deliveries can predispose to anal fissures
Inflammatory bowel diseases such as Crohn's disease

Symptoms

Anal fissures cause characteristic complaints:

Intense, burning or stabbing pain during and after bowel movements, which can last for minutes to hours
Bright red blood on toilet paper or in the stool (perianal bleeding)
Itching and discharge in the anal region
Spasmodic sphincter cramps after defecation
In chronic fissures: visible tissue changes such as a sentinel skin tag or indurated (hardened) fissure edges

Diagnosis

The diagnosis is typically established by clinical inspection of the anal area by a physician. The fissure is usually directly visible upon gentle separation of the buttocks. In many cases, a digital rectal examination is initially not possible due to severe pain. A proctoscopy (endoscopic examination of the rectum) may be performed after the acute symptoms subside or under anesthesia to rule out other conditions.

Treatment

Conservative Therapy

For acute anal fissures, conservative treatment is the first-line approach:

Stool regulation: A high-fiber diet, adequate fluid intake, and laxatives if necessary help keep stools soft and reduce pressure on the fissure.
Sitz baths: Warm sitz baths (e.g., with chamomile) relax the sphincter muscle and improve blood circulation.
Topical ointments: Anesthetic or anti-inflammatory creams help relieve pain.

Medical Therapy

For chronic anal fissures or inadequate response to conservative measures, specific medications are used to reduce elevated sphincter pressure:

Glyceryl trinitrate ointment (GTN): A topical nitrate that relaxes the internal anal sphincter and promotes healing. Common side effect: headaches.
Calcium channel blockers (e.g., topical nifedipine or diltiazem): Also relax the sphincter muscle locally.
Botulinum toxin injection: Botox is injected into the internal anal sphincter to temporarily paralyze it, allowing healing to occur. Highly effective for chronic fissures.

Surgical Therapy

For therapy-resistant chronic anal fissures, surgical intervention may be necessary:

Lateral internal sphincterotomy (LIS): A small portion of the internal anal sphincter is cut to reduce chronic muscle tension. Very high healing rate, but carries a small risk of fecal incontinence.
Fissurectomy: Surgical removal of the chronic fissure along with the altered surrounding tissue.

Prognosis

Acute anal fissures often heal within a few weeks with consistent conservative therapy. Chronic fissures typically require more targeted treatment but respond well in the majority of cases to botulinum toxin or surgery. Consistent stool regulation is essential to prevent recurrence.

References

Ommer A. et al. – S3-Leitlinie Analfissur, Deutsche Gesellschaft fuer Koloproktologie (DGK), AWMF-Register Nr. 081-008 (2020).
Nelson R.L. et al. – Non-surgical therapy for anal fissure. Cochrane Database of Systematic Reviews, 2012.
Breen E., Bleday R. – Anal fissure: Medical management. UpToDate, Wolters Kluwer, 2023.

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