An anal fissure can sometimes be confused with piles (haemorrhoids) because symptoms can be similar. If you have an anal fissure, you may have:
- a sharp, searing or burning pain in or around your anus, which can last for up to an hour after a bowel movement
- spasms in your anus
- a sentinel pile, which is a tag of skin that can develop on the edge of your anus below the fissure
After having a bowel movement, you may notice a streak of blood on the toilet paper or drops of blood in the toilet bowl.
These symptoms may be caused by something other than an anal fissure. But if you have any of these symptoms, see your GP.
Your GP will ask about your symptoms. They may examine the area by parting your buttocks as you lie on your side with your knees bent towards your chest. If your GP can see the fissure, they will discuss your treatment options with you.
If after about six weeks your symptoms haven’t improved with treatment, your GP may refer you to a colorectal surgeon. This is a surgeon who specialises in conditions that affect the bowel. At the hospital, your doctor will do a detailed examination under local anaesthesia. A local anaesthesia blocks pain from your anus and surrounding area, but you will stay awake during the procedure. You may also need to have an ultrasound scan of your anus.
To help an anal fissure heal, it’s important not to strain during a bowel movement and manage any pain caused by the fissure. Most anal fissures heal with changes to your diet and the right medicines. However, if the anal fissure doesn’t get better, you may need to have surgery.
Making changes to your diet and lifestyle can help prevent constipation and make your faeces softer, and therefore easier to pass. You can do this by:
- eating a balanced diet with lots of fibre
- taking a fibre supplement (bulk-forming laxative), such as sterculia (Normacol) or ispaghula husk (Fybogel)
- drinking enough fluids so that you don’t become dehydrated
- doing regular exercise
It may help to apply a lubricant, such as petroleum jelly, around your anus before you have a bowel movement. Sitting in a warm bath for 10 to 15 minutes after a bowel movement may also help relieve any discomfort.
Your GP may prescribe you a laxative, such as lactulose syrup, to soften your faeces. You can buy laxatives over the counter from a pharmacist without a prescription. However, it’s important to see your GP before trying laxatives because there are different types that work in different ways.
If you need pain relief, you can take over-the-counter painkillers such as paracetamol or ibuprofen.
Your GP may prescribe you the following medicines to relieve the spasm of an anal fissure.
- Local anaesthetic (eg, lidocaine). This may come as a cream, ointment or suppository (a medicine that you insert into your rectum) and will block pain from your anus.
- Glyceryl trinitrate. This is a rectal ointment that helps the internal sphincter muscle that goes around your anus to relax. It acts to reduce the spasm and improve blood flow to your anus to help the fissure heal.
- Calcium-channel blockers (eg, diltiazem cream). These medicines work by relaxing part of the sphincter to reduce the spasm and pressure in your anus. Calcium-channel blockers aren’t currently licensed in the UK to treat anal fissures but they can be prescribed by doctors for off-label use. This means the medicine is being used to treat a condition that it hasn’t been licensed for. However, doctors can legally prescribe outside the licence if he or she thinks the medicine will be effective for you.
Easing the anal spasm can help the fissure heal over a period of about four to six weeks. However, these treatments may not provide complete relief from your symptoms and you may need to use them with painkillers. Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your doctor or pharmacist for advice.
Botulinum A toxin (eg, Botox) is now being used more and more by surgeons. In this procedure, your surgeon injects botulinum A toxin into the internal sphincter muscle to help it relax. If a sentinel pile is present, your surgeon may remove it during the procedure to help aid healing. The effects of the treatment last around three months, by which time it's hoped the fissure will have healed. Like calcium-channel blockers, the use of botulinum A toxin is off-label.
If treatment with botulinum A toxin doesn’t work, your surgeon may suggest that you have a procedure called lateral internal sphincterotomy. During this procedure, your surgeon makes a small cut in the internal sphincter muscle to stop it from going into spasm. This means you will strain less when you go to the toilet and therefore less stress is put on the fissure, giving it time to heal. The procedure is usually done under general anaesthesia, which means you’ll be asleep during the operation.
As with any operation, there are possible complications associated with lateral internal sphincterotomy. Your doctor will talk to you about any that may apply to you so you’re fully informed before you go ahead with the surgery. Speak to your doctor for more information about treatments for anal fissure.
There are a number of reasons why you may develop an anal fissure. These include:
- straining during a bowel movement – often because you’re constipated
- recurrent or chronic diarrhoea
- inflammatory bowel disease, such as Crohn’s disease
- having an infection in the skin around your anus, such as a sexually transmitted infection or HIV
- being in the third trimester of pregnancy, or childbirth, if you're a woman
- taking certain medicines – for example, nicorandil (used to treat angina)
- trauma – for example, through anal intercourse
- anal cancer
- chemotherapy or radiotherapy
The main complication of an anal fissure is that it may take a while to heal, resulting in a chronic fissure. This can happen if:
- you have long-term constipation or diarrhoea
- the tear extends into the ring of muscle that holds your anus closed (this is known as your internal anal sphincter)
- pain causes your internal sphincter muscle to spasm, which can increase the pressure within your anus, making it harder to have a bowel movement
The more you strain when having a bowel movement, the less likely it is that the tear will heal.
You can reduce your risk of developing an anal fissure by preventing constipation. This is particularly important if you’ve had an anal fissure in the past. You can prevent constipation by eating a balanced diet rich in fibre, fruit and vegetables, drinking enough fluids and exercising regularly.
If you have a condition that increases your risk of having an anal fissure, speak to your doctor. They will discuss with you how to best manage your condition and reduce your risk of having an anal fissure.
Will my anal fissure get worse if I exercise?
No, it's important to continue to exercise as usual. Exercise helps to increase blood flow, which will help your anal fissure heal.
Exercise raises your heart rate, which increases blood flow around your body. This will help an anal fissure to heal. Being regularly active also helps to keep food moving through your digestive system, which helps to reduce constipation.
Remember, keeping physically active is great for your overall health – it can prevent major illnesses such as heart disease, diabetes and bowel cancer. You should aim to do 150 minutes (two and a half hours) of moderate exercise over a week in bouts of 10 minutes or more. Moderate intensity exercise includes brisk walking, swimming and cycling. Even housework and gardening can count as exercise, as long as you work hard enough to feel warmer and increase your heart rate.
If your anal fissure is painful when you exercise, see your GP as this may be a sign of another condition.
What is the treatment for a sentinel pile?
Sentinel piles (also called sentinel skin tags) can get better without treatment. However, you may need to have them surgically removed if they are large or cause you problems.
Sentinel piles are skin tags that can form if you have an anal fissure that has lasted a long time. They’re usually painless but you may notice that they become more painful over time. A sentinel pile may get better on its own, but it can become permanent as your anal fissure heals.
Sentinel piles can sometimes be left untreated because they don't often cause problems. However, it may be removed to help an anal fissure heal or if it grows and you start to notice it, or it’s causing you problems.
If you start to notice a sentinel pile, see your GP. He or she can discuss treatment options with you.
What is a sitz bath?
A sitz bath is when you sit in water that only covers your hips and buttocks – a bit like a portable bidet. Using a sitz bath with warm water may help relieve any discomfort you have after a bowel movement.
A sitz bath is a special type of bath, derived from the German word ‘sitzen’ meaning ‘to sit’. A sitz bath allows you to soak just your hips and buttocks. They are sometimes used to relieve pain, itching or muscle spasms.
Sitz baths help to promote good anal hygiene, can decrease anal sphincter spasm and improve blood flow to the lining of your anus. A warm sitz bath for 10 to 15 minutes after a bowel movement may help to relieve the pain. There isn’t, however, any evidence to prove that sitz baths are an effective treatment.
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Reviewed by Alice Rossiter, Bupa Health Information Team, August 2014.
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