Anal fissure

The key answer

An anal fissure most often causes sharp pain during bowel movements, burning or spasm after stool and bright red blood on toilet paper. The problem often starts after hard stool, constipation, diarrhoea or strong straining. If symptoms persist, recur, cause fear of bowel movements or do not improve despite stool regulation, it is worth seeing a proctologist. Treatment depends on whether the fissure is fresh, chronic or accompanied by excessive sphincter tension.

What is an anal fissure?

An anal fissure is a tear in the lining of the anal canal. Although the lesion may be small, it can cause very severe pain because the anal area is richly innervated, and during bowel movements the wound is irritated by stool and sphincter tension.

In some patients, the fissure heals with appropriate conservative management. In others, it becomes chronic: pain returns with every bowel movement, the patient begins avoiding defecation, constipation worsens and the wound does not have favourable conditions to heal.

Symptoms of anal fissure

• sharp, cutting or burning pain during bowel movements,
• pain described as “glass”, “wound”, “cut” or “tear”,
• burning or anal spasm lasting after stool,
• bright red blood on toilet paper, stool or in the toilet bowl,
• fear of bowel movements because of pain,
• worsening constipation because the patient delays going to the toilet,
• a feeling of a wound, stinging or hypersensitivity in the anal canal,
• sometimes itching, moisture, skin irritation or a sentinel tag.

Why does an anal fissure develop?

The most common mechanism is mechanical trauma to the mucosa — usually after hard stool, constipation, strong straining or diarrhoea. The injury causes pain, pain triggers reflex sphincter spasm, and spasm worsens blood flow and makes healing more difficult. This may create the fissure cycle.

Common contributing factors

• constipation and hard stool,
• diarrhoea and frequent bowel movements,
• strong straining in the toilet,
• low fibre and fluid intake,
• delaying bowel movements because of pain,
• postpartum period,
• irritation of the anal area,
• inflammatory bowel disease or infections — especially in an atypical course.

Acute and chronic anal fissure — what is the difference?

Acute anal fissure is short-lasting and often has a chance to heal after stool regulation, reducing straining, pain control and limiting wound irritation. The key is to break the cycle: hard stool → pain → spasm → even more pain.

Chronic anal fissure lasts longer, recurs or has features of impaired healing. It may be accompanied by increased sphincter tension, a sentinel tag, chronic spasm and fear of bowel movements. In this situation, simply waiting or using hemorrhoid ointment is often not enough.

Anal fissure or hemorrhoids?

Anal fissure and hemorrhoids may both cause bright red blood on toilet paper, which is why they are often confused. The difference lies in the dominant symptom. With a fissure, the patient most often describes severe pain during stool — like a wound, glass or a cut. With hemorrhoids, bleeding, itching, moisture, a lump or prolapse are more common, although pain may also occur, especially with thrombosis or a coexisting fissure.

It is not always possible to distinguish them by description alone. Sometimes the patient has both hemorrhoids and a fissure. That is why diagnosis requires proctological consultation.

When should you see a proctologist?

With symptoms such as fever, purulent discharge, increasing throbbing pain or a rapidly enlarging lump, the doctor must rule out an abscess, thrombosed external hemorrhoid or another cause of pain. This is not a situation for prolonged home treatment.

What does diagnosis of an anal fissure look like?

During consultation, the doctor asks about pain, blood, symptom duration, constipation, diarrhoea, diet, medication, previous treatment and bowel diseases. Then the anal area is assessed. The examination should be adjusted to the pain — with a very fresh and painful fissure, the full examination may be postponed or performed very gently.

If indicated and tolerated by the patient, the doctor may perform anoscopy to assess the anal canal, rule out another source of bleeding and plan treatment. Anoscopy does not replace colonoscopy if symptoms suggest a problem higher in the bowel.

How is an anal fissure treated?

Treatment depends on symptom duration, wound appearance, sphincter tension and factors that impair healing. The goal is to reduce pain, make bowel movements easier, relax spasm and create conditions for healing.

1. Stool regulation and conservative treatment

For many patients, the foundation is softening stool, avoiding straining, adequate fluids, fibre adjusted to tolerance, treatment of constipation or diarrhoea and local treatment recommended by the doctor. It is important to avoid repeated injury to the wound with hard stool.

2. Local treatment

The doctor may recommend preparations that reduce pain, inflammation or sphincter tension. It is not worth using many ointments at once without a diagnosis, because some products may irritate the skin or mask another cause of symptoms.

3. Botulinum toxin

In chronic anal fissure, especially when sphincter spasm is present and conservative treatment does not bring improvement, the doctor may consider botulinum toxin injection. Its role is to temporarily relax the sphincter, reduce pain and improve conditions for wound healing.

4. Surgical treatment

In some patients, especially with chronic, treatment-resistant fissures, the doctor may discuss surgical treatment. The decision depends on the clinical picture, recurrence risk, sphincter tension, previous treatment and the patient’s individual situation.

What should you avoid if you suspect an anal fissure?

• do not automatically assume it is hemorrhoids,
• do not prolong constipation and do not delay bowel movements because of fear of pain,
• do not use many ointments at once without a diagnosis,
• do not use aggressive hygiene products or perfumed wet wipes,
• do not ignore blood, even if there is only a small amount,
• do not wait for weeks if pain returns with every bowel movement,
• do not try to diagnose on your own whether the fissure is acute or chronic.

What should you remember before the visit?

• how long the pain has been present and whether it occurs with every stool,
• whether the pain is sharp, cutting, burning, throbbing or spasmodic,
• whether it lasts after bowel movement — minutes or hours,
• whether there is bright red blood on toilet paper or stool,
• whether constipation, diarrhoea, hard stool or strong straining are present,
• which ointments, suppositories or medications have been used,
• whether symptoms have occurred before and whether they recur,
• whether there are other symptoms: fever, pus, lump, weight loss, weakness or a change in bowel habits.

Diagnostic and treatment pathway at Wyspa Medycyny Przyjaznej

Not every fissure requires a procedure. First, the diagnosis must be confirmed, the doctor must assess whether the fissure is fresh or chronic and check what prevents healing.

This page describes the condition and symptoms of anal fissure. A detailed description of botulinum toxin treatment is available on a separate service page to avoid duplicating procedure content.

Who diagnoses and treats anal fissure?

Pain like a wound or glass during bowel movements?

It may be an anal fissure. Do not treat the symptom blindly — book a consultation and check whether conservative treatment, anoscopy, botulinum toxin or further diagnostics are needed.

Fictional patient voices — common concerns about anal fissure

Note: the statements below are illustrative and educational. They are not real patient reviews or clinic testimonials. They may only be published as fictional voices showing common concerns.

Frequently asked questions about anal fissure

Read more — fissure, pain and proctological diagnosis

The links below guide the patient from symptom to action: consultation, anoscopy, botulinum toxin treatment for fissure or differentiation from hemorrhoids.

Book a consultation for anal fissure

The doctor will assess whether pain and bleeding are caused by an anal fissure, hemorrhoids, thrombosed external hemorrhoid, abscess, inflammation or another condition requiring treatment.