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Anal fissure

An anal fissure is a small tear or ulcer (open sore) in the skin around the opening of your anus. It can cause severe pain, especially after a bowel movement.

About anal fissure

Anal fissures are usually found at the rear of your anus – in line with the cleft of your buttocks. A fissure can also occasionally occur at the front of your anus.

 Illustration showing the anus with an anal fissure

An anal fissure usually heals within one to four weeks, although it can take up to six weeks. This is known as an acute anal fissure. If it lasts for longer than six weeks, it’s known as a chronic anal fissure.

Although an anal fissure can occur at any age, it’s most common in people aged 15 to 40.

Symptoms of anal fissure

An anal fissure can sometimes be confused with piles (haemorrhoids) because the symptoms are 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 around an hour after a bowel movement and is severe
  • 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 your toilet paper or drops of blood in the toilet bowl.

If you have any of these symptoms, see your GP.

Complications of anal fissure

The main complication of an anal fissure is that it may fail 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 (internal sphincter muscle)
  • the pain causes your internal sphincter muscle to go into spasm, which can increase the pressure within your anus, and make it even harder for you to have a bowel movement

The more you strain when having a bowel movement, the less likely it is that the tear will heal.

Causes of anal fissure

There are a number of reasons why you may develop an anal fissure. These include:

  • straining during a bowel movement – often because of constipation
  • recurrent or chronic diarrhoea
  • inflammatory bowel disease, such as Crohn’s disease
  • sexually transmitted infections – an infection in the skin around your anus can cause a tear
  • being in the third trimester of pregnancy, or childbirth, if you're a woman
  • HIV infection
  • taking certain medicines – for example nicorandil
  • trauma – through anal intercourse
  • anal cancer
  • chemotherapy or radiotherapy

Diagnosis of anal fissure

Your GP will ask about your symptoms. He or she may examine the area by gently parting your buttocks. If your GP can see the fissure, he or she will usually prescribe treatment.

If after about six weeks your symptoms haven’t improved with treatment, your GP may refer you to a colorectal surgeon (a doctor who specialises in conditions that affect the bowel). At the hospital, your doctor will do a detailed examination under local anaesthesia – this helps to reduce your discomfort during the procedure. You may also need to have an ultrasound scan of your anus.

Treatment of anal fissure

To help an anal fissure heal it’s important to stop straining during a bowel movement and manage the pain caused by the fissure. Most anal fissures heal with dietary changes and the use of medicines. However, if the anal fissure doesn’t get better, you may need to have anal fissure surgery.

Self-help

Making changes to your diet and lifestyle can help prevent constipation and make your faeces softer. You can do this by:

  • eating a balanced diet with lots of fibre
  • drinking enough fluids so that you don’t become dehydrated
  • taking regular exercise

It may help to use 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 relieve your discomfort.

Medicines

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 a good idea to see your GP before trying laxatives as 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 (medicine that you put into your rectum) and will completely block the pain from your anus.
  • Glyceryl trinitrate. This is a rectal ointment that will relax the internal anal sphincter muscle. It acts to reduce the spasm and improve the blood flow to your anus to help the fissure heal.
  • Calcium-channel blockers (eg diltiazem). These medicines act 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 and isn’t listed in the patient information leaflet that comes with the medicine. A doctor can legally prescribe outside the licence if he or she thinks the medicine will be effective for you.

Easing the anal spasm helps the fissure to heal over a period of about four to six weeks. However, these treatments don’t provide instant 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.

Surgery

Increasingly, botulinum A toxin is being used by surgeons to produce a ‘chemical sphincterotomy’. In this procedure, your surgeon injects botulinum A toxin into the internal sphincter muscle to help it relax. The effects of the treatment last about 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 you have a procedure called lateral internal sphincterotomy. Your surgeon will make 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 so a reduced amount of stress is put on the fissure, giving it time to heal. The procedure is usually done under general anaesthesia. This means you will be asleep during the operation.

Speak to your doctor for more information about treatments for anal fissure.

Prevention of anal fissure

You can reduce your risk of anal fissure by preventing constipation. This is particularly important if you have 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. He or she will discuss with you how to best manage your condition and reduce your risk of having an anal fissure.

 

Produced by Krysta Munford, Bupa Health Information Team, December 2012.

For answers to frequently asked questions on this topic, see FAQs.

For sources and links to further information, see Resources.

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  • This information was published by Bupa's Health Information Team and is based on reputable sources of medical evidence. It has been reviewed by appropriate medical or clinical professionals. Photos are only for illustrative purposes and do not reflect every presentation of a condition. The content is intended only for general information and does not replace the need for personal advice from a qualified health professional. For more details on how we produce our content and its sources, visit the about our health information page.

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