Anal pain, burning, bleeding during bowel movements and a feeling of a “wound” in the anal canal may suggest an anal fissure, but similar symptoms may also occur with haemorrhoids, perianal thrombosis, inflammation, abscess, fistula or other anal conditions. That is why proctological diagnostics are needed before starting treatment — including before qualification for botulinum toxin treatment.
This article explains how to distinguish an anal fissure from haemorrhoids, when conservative treatment may be enough, when botulinum toxin can be considered and what role proctological physiotherapy may play. If you have pain, bleeding, burning or recurrent symptoms, book a proctology consultation in Gdańsk.
Author: Justyna Szul, MD, proctologist | Medical review: Dr Kamil Smok, surgeon and proctologist | Publication date: 29.06.2026 | Last updated: 29.06.2026
Why is diagnostics before treatment so important?
Proctological symptoms are often very similar. A patient may see blood on toilet paper, feel burning, pain during bowel movements or a lump near the anus and assume it is “haemorrhoids”. Another patient may be convinced they have an anal fissure because the pain is sharp and appears during stool passage.
In practice, it is easy to be wrong without an examination. Similar symptoms may be caused by:
- anal fissure, a tear in the lining of the anal canal,
- haemorrhoids, symptomatic enlargement of haemorrhoidal cushions,
- perianal thrombosis, a painful lump at the anal margin,
- perianal abscess, especially when pain increases and swelling or fever appears,
- anal fistula, especially with recurrent discharge or abscesses,
- inflammatory conditions of the skin and mucosa,
- polyps, mucosal lesions or cancer-related lesions that require separate diagnostics.
That is why the aim of the first visit should not be to automatically start a specific treatment, but to identify the cause of symptoms. Only after diagnosis can the doctor decide whether conservative treatment, physiotherapy, haemorrhoid treatment, fissure treatment, botulinum toxin, surgery or further diagnostics is needed.
Anal fissure or haemorrhoids — how may they differ?
This is one of the most common questions asked by patients searching Google for “anal pain — what could it be?”, “causes of rectal bleeding” or “pain during bowel movements”. Symptoms may overlap, but certain features can help guide diagnostics.
| Feature | Anal fissure | Haemorrhoids |
|---|---|---|
| Pain | often sharp, burning, cutting; worsens during bowel movement and may persist afterwards | more often discomfort, itching, burning or a feeling of moisture; severe pain is not typical for internal haemorrhoids alone |
| Bleeding | usually a small amount of bright red blood, often on toilet paper | bright red blood during bowel movement, sometimes without pain |
| Lump / prolapse | a sentinel skin tag may sometimes coexist with a chronic fissure | prolapse of haemorrhoidal cushions, a feeling of obstruction or moisture may occur |
| Typical situation | pain after hard stool, constipation, diarrhoea or mucosal trauma | bleeding, itching, prolapse, worsening with constipation, straining and long toilet sitting |
In practice, symptoms may overlap. A patient may have both an anal fissure and haemorrhoids, and severe pain may have another cause than either of these conditions. That is why the final diagnosis requires proctological examination.
Read also: haemorrhoid treatment in Gdańsk and rectal bleeding — when does it require diagnostics?
“Patients often come in with a diagnosis from the internet: haemorrhoids or a fissure. Our job is first to check what is actually causing pain and bleeding, because the entire treatment plan depends on that.”
— Justyna Szul, MD, proctologist
Does every anal fissure require botox?
No. Not every anal fissure requires treatment with botulinum toxin. In many patients, the first stage is conservative treatment, especially when the fissure is recent, symptoms have been present for a short time and there are no features of a chronic, established lesion.
Conservative treatment may include:
- stool regulation and constipation treatment,
- adequate fibre and fluid intake,
- avoiding strong straining,
- relief of pain and irritation,
- topical medication selected by the doctor,
- warm sitz baths or hygiene recommended by the doctor,
- working on sphincter and pelvic floor tension, if indicated.
Botulinum toxin is usually considered when the problem is chronic, persists despite conservative treatment, increased sphincter tone coexists or the doctor decides that this method may be appropriate for a specific patient.
The service page about this method is available here: botulinum toxin treatment for anal fissure in Gdańsk.
When can botox be considered?
Botulinum toxin works by temporarily reducing the tone of the internal anal sphincter. In some patients, this may improve fissure healing conditions, because excessive sphincter tone may reduce blood flow and maintain pain.
Botox may be considered especially when:
- the fissure is chronic,
- symptoms persist despite conservative treatment,
- pain and sphincter spasm worsen the problem,
- the patient has recurrent fissure episodes,
- the doctor confirms qualification after examination,
- there are no symptoms suggesting another condition requiring different treatment.
A patient should not be qualified for botulinum toxin solely based on symptom description. First, the diagnosis must be confirmed and haemorrhoids, abscess, fistula, inflammation or lesions requiring another approach should be excluded.
The role of proctological and pelvic floor physiotherapy
Proctological physiotherapy is not a method of “closing” an anal fissure and does not replace diagnostics or medical treatment. However, it may be an important part of therapy in selected patients, especially when the problem is related to excessive pelvic floor tension, abnormal straining, constipation or difficulty relaxing during bowel movements.
Physiotherapy may help with:
- learning proper bowel movement mechanics,
- reducing abnormal straining,
- working with breathing and pelvic floor tension,
- learning to relax muscles during defecation,
- reducing overload of the anal area,
- recurrence prevention in selected patients.
In practice, a combined approach often works best: stool regulation, topical treatment, toilet habit changes, work on muscle tension and — if indicated — botulinum toxin or other treatment methods. The order is decided by the doctor after examination.
Why is ointment alone sometimes not enough?
Ointments and suppositories may relieve pain, burning and inflammation, but they do not always remove the cause of the problem. If the patient has hard stools, chronic constipation, strong straining, excessive sphincter tone or abnormal bowel movement mechanics, symptoms may return despite using another topical preparation.
It is worth seeing a proctologist if:
- pain during bowel movements persists despite treatment,
- blood appears repeatedly,
- symptoms return after stopping ointments,
- pain continues long after a bowel movement,
- a lump, swelling or purulent discharge appears,
- symptoms last longer than a few weeks,
- alarm symptoms occur: fever, increasing pain, significant bleeding, weakness, weight loss or a change in bowel habits.
What can be assessed during proctological examination and anoscopy?
Anoscopy allows the doctor to view the anal canal and lower rectum. It is not always performed immediately — in severe pain, the doctor may start with gentle inspection and external examination, and perform a more complete assessment when it is possible and tolerated by the patient.
During proctological examination and anoscopy, the doctor may assess or suspect, among others:
- anal fissure — a tear in the lining of the anal canal,
- haemorrhoids — haemorrhoid treatment,
- perianal thrombosis — haemorrhoidal thrombosis,
- anal fistula — anal fistula treatment,
- rectal or anal canal polyps — rectal polyps,
- perianal abscess — especially with severe, increasing pain and swelling,
- inflammatory conditions of the skin, mucosa or anal area,
- lesions requiring urgent or extended diagnostics, including oncologically suspicious lesions.
Note: pilonidal disease usually affects the natal cleft and coccygeal area, so anoscopy is not the primary examination for its diagnosis. In this case, external examination of the sacrococcygeal area is more important.
More about the examination: anoscopy — anal examination.
What does a consultation before fissure treatment look like?
The consultation is intended to determine what is truly causing the symptoms and which treatment method will be safest and most appropriate for the patient’s situation.
The visit may include:
- Medical history — the doctor asks about pain, bleeding, constipation, diarrhoea, symptom duration, previous treatment and comorbidities.
- Assessment of the anal area — inspection alone often allows the doctor to suspect a fissure, thrombosis or abscess.
- Digital rectal examination — if indicated and possible without excessive pain.
- Anoscopy — if the patient tolerates it and the doctor considers it necessary.
- Treatment plan — conservative, physiotherapeutic, with botulinum toxin, procedural or requiring further diagnostics.
If pain is very severe, the doctor may adjust the scope of examination to the patient’s tolerance. The goal is not “examination at all costs”, but safe diagnosis and treatment planning.
When should you not delay consultation?
It is worth seeing a proctologist if pain, bleeding or burning recur, worsen or do not improve despite treatment. Consultation is especially important when symptoms are new or have changed in character.
Do not delay a visit if you have:
- severe pain during bowel movements,
- pain that persists long after passing stool,
- rectal bleeding, especially recurrent,
- a lump near the anus,
- purulent discharge or drainage,
- fever or increasing swelling,
- a feeling of incomplete evacuation,
- weight loss, anaemia or a change in bowel habits.
For bleeding, read also: rectal bleeding — when is it a reason for concern?
Who can you see at Wyspa Medycyny Przyjaznej?
At Wyspa Medycyny Przyjaznej in Gdańsk, proctology consultations are provided by doctors dealing with diagnosis and treatment of anal and rectal diseases. With symptoms of fissure, haemorrhoids, bleeding, pain or burning, you can book a visit with:
- Sara Godyńska, MD, proctologist,
- Justyna Szul, MD, proctologist,
- Dr Kamil Smok, surgeon and proctologist.
Booking:
Book a proctology consultation in Gdańsk
Book online via ZnanyLekarz
Frequently asked questions
Does anal pain mean a fissure?
Not always. Sharp pain during bowel movements may suggest a fissure, but similar symptoms may occur with perianal thrombosis, abscess, inflammation or other anal diseases. Proctological examination is needed.
How can you distinguish an anal fissure from haemorrhoids?
A fissure more often causes sharp, cutting pain during and after bowel movements. Haemorrhoids more often cause bleeding, itching, moisture or prolapse. Symptoms may overlap, so diagnosis requires examination.
Does every anal fissure require botox?
No. In many cases, treatment begins with conservative methods: stool regulation, constipation treatment, topical medication, habit changes and sometimes physiotherapy. Botox is considered in selected patients after qualification.
Is anoscopy always necessary?
Not always immediately. Anoscopy is very helpful in diagnosing the anal canal, but in severe pain the doctor may adjust the examination to the patient’s tolerance and perform a fuller assessment later.
Can physiotherapy help with an anal fissure?
In selected patients, yes — especially when the problem is related to excessive pelvic floor tension, abnormal straining, constipation or difficulty relaxing during bowel movements.
When should I urgently see a proctologist?
Urgent assessment is needed for severe increasing pain, fever, purulent discharge, a rapidly enlarging lump, heavy bleeding, weakness, weight loss or a change in bowel habits.
Pain, burning or blood during bowel movements?
Do not assume immediately that it is haemorrhoids or a fissure. Start with diagnostics — treatment choice depends on it.
Book a proctology consultation →Summary
Anal pain, burning and bleeding may be caused by an anal fissure, haemorrhoids, perianal thrombosis, abscess, fistula, inflammation or other anal diseases. That is why proctological diagnostics are needed before treatment.
Not every anal fissure requires botulinum toxin. In many patients, treatment begins with conservative methods: stool regulation, constipation treatment, topical medication, toilet habit changes and sometimes physiotherapy. Botox is one option, but it requires qualification.
The most important step is correct diagnosis. Only then can treatment be selected according to the actual cause of symptoms, instead of treating haemorrhoids, a fissure or anal pain “blindly”.
Read also
- Proctologist Gdańsk — proctology hub
- Botulinum toxin treatment for anal fissure in Gdańsk
- Anoscopy — proctological examination
- Haemorrhoid treatment in Gdańsk
- Rectal bleeding — diagnostics
- A lump near the anus — causes
- Anal pain when sitting — causes
- Perianal thrombosis — symptoms and treatment
- Perianal abscess — symptoms and urgent consultation
Sources and medical context:
- American Society of Colon and Rectal Surgeons — Management of Anal Fissures, 2023
- NICE — Chronic anal fissure: botulinum toxin type A injection
- Cleveland Clinic — Anoscopy: What to Expect
- Cleveland Clinic — Hemorrhoids: symptoms and difference from anal fissure
- Mayo Clinic — Anal fissure: diagnosis and treatment
- Wyspa Medycyny Przyjaznej — proctology consultation in Gdańsk
This article is for informational purposes only and does not replace medical consultation. Severe increasing anal pain, fever, purulent discharge, a rapidly enlarging lump, heavy bleeding, anaemia, weight loss, change in bowel habits or rapid deterioration of general condition require individual medical assessment.