Anal Fissure

What is an Anal Fissure?

Anal fissure is a small tear in the skin that lines the anus. Chronic fissures often have a small external lump associated with the tear called a sentinel pile or skin tag.

The typical symptoms of an anal fissure are pain during or after passing stool and bleeding.

What Causes an Anal Fissure?

Anything that irritates the inner lining of the anus can cause a fissure. Typically caused by hard or large stool overstretching the anal canal is responsible for a fissure. Other causes include diarrhea or inflammatory conditions of the anal area.

Fissures located in atypical locations may be because of Crohn’s disease, ulcerative colitis, anal tuberculosis, HIV infection and cancer. Biopsies of these fissures are mandatory.

How to Diagnose an Anal Fissure?

Inflammatory bowel disease, infections, or anal growths (skin tumors) can cause fissure-like symptoms, and patients suffering from persistent anal pain should be examined to exclude these conditions.

Careful examination of anal area is required to diagnose anal fissure.

Other Investigations may sometimes be needed

Anal Manometry

Manometry is not used routinely; it is useful in evaluating patients with recurrent fissures, elderly patients with pre-existing incontinence and multi gravid women with possible pre-existing sphincter defects as this allows the surgeon to decide on the procedure of choice.


Persistence of symptoms after medical treatment in patient below 50 years of age should be advised for sigmoidoscopy.

Any patient above the age of 50 years who presents with per rectal bleeding should be advised for full colonoscopic evaluation.

How a Fissure is Treated?

General measures (conservative approach)

  • An acute fissure is typically managed with non-operative treatments and over 90% will heal without surgery. Often treating constipation or diarrhea can cure a fissure

  • High fiber diet, bulking agents, stool softeners, and plenty of fluids help relieve constipation, promote soft bowel movements, and help in the healing process. Increased dietary fiber may also help to improve diarrhea.

  • Warm baths for 10-20 minutes several times each day are soothing and promote relaxation of the anal muscles, which can also help healing.

  • Use of moist tissues or shower spray is often better alternative to toilet paper after bowel movements. – See more at:

  • Simple hygiene practices like washing the perineum and padding dry is recommended

  • Sitz Baths – Sitting in a tub filled with lukewarm water with or without 2 tablespoonfuls of salt provide comfort by relaxing the anal tone and relieving the pain.

Medical Therapy

  • Topical anesthetics such as 2% lignocaine may be recommended.

  • Topical Nitrates Application around the perianal skin 2 to 3 times a day is shown to improve the local blood flow and reduce the pressure exerted by the internal anal sphincter, thereby increasing the chances of healing.

  • Topical Calcium Channel Blockers These act mainly by reducing the internal anal sphincter pressure.

  • Botox Injection of botulinum toxin into the internal anal sphincter (‘chemical sphincterotomy’) results in reduction of the internal anal sphincter pressure. Effect lasts for 2-3 months, allowing the fissure to heal

Surgery (Lateral Internal Spincterotomy)

  • Surgery is a highly effective treatment for chronic fissure and recurrence rates after surgery are low.

  • Surgery usually consists of a small operation to cut a portion of the internal anal sphincter muscle. This helps the fissure heal and decreases pain and spasm.

  • If a sentinel pile is present, it may be removed to promote healing of the fissure.

  • Botox Injection of botulinum toxin into the internal anal sphincter (‘chemical sphincterotomy’) results in reduction of the internal anal sphincter pressure. Effect lasts for 2-3 months, allowing the fissure to heal.

Fissure at a Glance

  • Anal fissures are associated with pain. Bleeding from piles is usually painless.

  • Most acute fissures heal with conservative measures.

  • General measures- fluid intake, ensuring soft consistency of stools and symptomatic relief with topical anesthetics and analgesics.

  • Medical therapy is a good option for acute fissures although the efficacy and complication rates are variable.

  • Most patients with chronic anal fissures will require surgical treatment, which have excellent results. These are routinely performed in a day surgery setting.

  • Recurrent fissures should be evaluated by an experienced coloproctologist with adjunct investigations such as anal manometry and endoanal ultrasonography before deciding on the appropriate therapy.

  • A typically located fissures must be biopsied to rule out certain severe diseases.

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