An anal fissure is a small longitudinal tear in the lining of the anal canal. Its characteristic symptom is sharp burning pain with a bowel motion that persists for minutes to hours afterwards, together with bright red blood on the surface of the stool or on the paper. It usually starts after passing hard stool, severe diarrhoea or childbirth, and then enters a vicious circle: pain makes the internal sphincter spasm, the spasm reduces blood flow to the fissure, healing is delayed and the pain continues. Treatment therefore always begins by breaking that circle without surgery: softening the stool with fibre, fluids and laxatives so it passes without straining, warm sitz baths in plain water to relax the muscle, and prescribed topical ointments that either relax the sphincter or relieve pain. Most acute fissures heal with these measures over a few weeks, provided they are followed consistently rather than intermittently. If a fissure persists beyond six to eight weeks it is considered chronic, usually with a skin tag at its outer edge and a thickened papilla inside. At that stage further options are considered: injection of an agent that temporarily relaxes the sphincter, lateral internal sphincterotomy, which lowers muscle tone so the fissure can heal, or an advancement flap in selected cases such as a weak sphincter or a fissure that recurred after previous surgery. The limits should be explicit. Surgery treats the fissure but does not change bowel habits: if constipation and straining continue, the fissure may return, so stool regulation remains a permanent part of the plan rather than a phase that ends. Any intervention on the sphincter carries a possible effect on control of wind or stool, so it is never done automatically but weighed carefully, especially in women after several deliveries and in anyone with pre-existing leakage or sphincter weakness. Also, not every anal pain with bleeding is a simple fissure: **a fissure that is lateral rather than in the anterior or posterior midline, or multiple fissures, or one that fails to heal with correct treatment, calls for a search for another cause such as Crohn disease, infection or a tumour.** Which step suits you is decided by clinical examination, not by self-diagnosis, because fissure, haemorrhoids, fistula and abscess share symptoms yet are treated in entirely different ways.
Procedure steps
- 1
Diagnosis and examination
The doctor gently inspects the area to see the fissure and its position and to decide whether it is acute or chronic, distinguishing it from haemorrhoids, fistula and abscess. Inspection alone may suffice when pain is severe, with anoscopy or examination under anaesthesia added later if needed.
- 2
Conservative treatment first
The plan starts with softening the stool using fibre, fluids and laxatives, warm sitz baths several times a day, and prescribed topical ointments to relax the muscle or ease pain, continued for weeks rather than days. Consistency is what heals; stopping at the first improvement is the commonest reason treatment fails.
- 3
Reassessment
You are reviewed after some weeks to judge the response: has the post-defaecation pain gone, has bleeding stopped, are there signs of chronicity. Sphincter tone and any pre-existing leakage are assessed, and features suggesting another cause are sought if the fissure has not improved.
- 4
Intervention when needed
For a chronic fissure the option is chosen to fit you: a sphincter-relaxing injection, lateral internal sphincterotomy, or an advancement flap. It is usually done under short anaesthesia as a day case, and the balance between chance of healing and possible effect on continence is explained beforehand.
- 5
Follow-up and preventing recurrence
You are followed up to confirm the fissure has healed and the pain has gone, and stool regulation with water, fibre and activity continues after healing, not only before it. If there is weak control or a habit of chronic straining, pelvic floor rehabilitation or biofeedback may be added to the plan.
Before the procedure
Before your appointment, note the details of your symptoms: when the pain started, whether it comes with defaecation or is constant, how long it lasts afterwards, and the colour and amount of blood. Tell the doctor about your medicines, especially blood thinners and aspirin, about any drug allergy, and about chronic conditions such as diabetes. State clearly whether you have any leakage of wind or stool or a sense of weak control, and whether you have had several deliveries or a tear during childbirth, since this genuinely changes any decision to operate on the sphincter. Describe precisely which treatments you have tried and for how long: many cases are labelled as treatment failures when in reality the treatment was never used for the right duration or in the right way. If a surgical step is planned, ask about fasting, arrange an escort and a day or two off work, and do not stop your laxatives before surgery unless told to.
After the procedure
Keep softening your stool with water, fibre and the prescribed laxative: this is the single most important factor in healing and in preventing recurrence, so do not stop it as soon as the pain settles. Take warm sitz baths in plain water after every bowel motion and whenever you have pain, and dry the area gently. Use the prescribed ointments for the full stated period; some can cause a mild headache in the first days, so tell your doctor if it troubles you rather than stopping the treatment yourself. Do not sit long on the toilet or push, and avoid perfumed wipes and harsh soap on the area. After a surgical step, expect discomfort and minor bleeding for some days, and avoid heavy lifting and vigorous exercise for one to two weeks as instructed. **Seek care immediately for heavy bleeding that does not stop with pressure, severe worsening pain after a calmer day, fever and chills, swelling with redness and pus, inability to pass urine, or any leakage of stool or wind that was not present before the procedure.**
Expected duration
The conservative route runs over weeks of consistent home treatment with reviews, while the surgical step usually takes 15 to 30 minutes under short anaesthesia as a day case.
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