Prevention & care

Anal fissure: a tear versus hemorrhoids, acute and chronic disease, stool care, medicines, surgery, and continence

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An anal fissure is a small tear in the lining at the anal opening. It commonly causes sharp pain when passing stool, pain afterward and bright-red bleeding. This is a different lesion from hemorrhoids. A familiar symptom pattern helps assessment, but rectal pain or bleeding still requires the correct cause to be identified.[1]

The categories change the question

The categories change the question
Category	Meaning
Acute	ASCRS defines symptoms present for less than six weeks.[3]
Chronic	Longer duration, often with characteristic examination findings.[3]
Atypical	An unusual location or pattern requiring broader investigation.[2]
Hemorrhoids	Another possible cause of anal symptoms, rather than a synonym for a tear.[1]

Hard stools and diarrhea can both cause local injury

ASCRS explains a cycle in which injury produces pain, internal sphincter spasm and reduced local blood flow, impairing healing. A hard, dry bowel movement is one trigger, but loose stools can also cause injury. This explains why treating the bowel pattern and reducing muscle spasm can address different parts of the same problem.[3]

Persistent or unusual symptoms need another look

ASCRS advises re-examination when conservative measures fail. Crohn’s disease, infection and anal tumors can produce similar symptoms. Fissures outside the usual midline location particularly need further assessment. A fissure does not itself become colorectal cancer, but finding one does not establish that all current or future bleeding has that explanation.[2]

Nonoperative care aims to make bowel movements less traumatic

The NHS describes maintaining soft stools, adequate fluid and fiber, appropriate treatment of constipation and warm baths for comfort. A clinician may prescribe a stool-softening treatment. Pain can make people reluctant to pass stool, which can complicate bowel habits. The goal is sustained improvement in the stool pattern and healing, not simply suppressing one painful episode.[1]

Prescription creams act on muscle tone and have different harms

ASCRS describes topical nitrates and calcium-channel blockers such as diltiazem or nifedipine as sphincter-relaxing treatments. Headache and lowered blood pressure can occur, particularly with nitrates. A topical formulation is not interchangeable with an oral medicine used for another condition. Choice, preparation and monitoring depend on a clinician’s assessment and local availability.[2]

The 2020 topical-treatment review did not establish superior healing

Nine randomized trials compared topical diltiazem with glyceryl trinitrate for chronic fissures. The healing analysis included 379 and 351 patients respectively: pooled risk ratio 1.04, 95% confidence interval 0.93–1.16. The interval includes no difference, so the review does not demonstrate that diltiazem heals more fissures.[4]

Headaches were less frequent with diltiazem, while four trials suggested lower late recurrence. Trials varied in treatment duration, follow-up and reported methods. The review’s table often leaves funding or blinding unspecified, and it reports no financial support for the review. Short-term healing, tolerability and long-term recurrence are distinct outcomes.[4]

The 2023 guideline distinguishes acute care and selected chronic treatment

ASCRS searched adult English-language literature through March 2022. It supports nonoperative care initially for acute fissures, and recognizes topical calcium-channel blockers as having similar healing to nitrates with a better adverse-effect profile. Its recommendations synthesize prior studies and clinical judgment; this Atlas explanation has not independently repeated that assessment.[3]

Healing and continence are both important outcomes

Botulinum toxin relaxes the sphincter through injection. Lateral internal sphincterotomy divides part of that muscle; it is an option for selected chronic fissures. ASCRS emphasizes existing incontinence, obstetric sphincter injury, prior anorectal surgery and inflammatory bowel disease when considering surgery. Tailored division can reduce continence harms relative to a longer division.[3]

Symptom relief and tissue healing have different timelines

ASCRS describes pain improving before complete healing in some treated patients. A healed fissure may recur after another injurious bowel movement. Maintaining appropriate bowel habits and reassessing unexplained recurrence remain relevant after a successful treatment, rather than assuming that one procedure answers every future anal symptom.[2]

Duration, appearance and location describe different categories

The Italian guideline describes acute fissures as present for less than six weeks and chronic fissures as longer-lasting tears with changes such as thickened edges or an accompanying skin tag. Typical fissures are usually solitary and lie in the midline. Multiple or off-midline fissures are atypical and can warrant investigation for another condition. These categories answer separate questions: duration helps describe healing, while location and number influence whether the presumed cause needs reconsideration.[6]

Cutting muscle and preserving muscle have different tradeoffs

Sphincterotomy divides part of the internal anal sphincter to reduce resting pressure. Tailored sphincterotomy limits the extent of that division. Fissurectomy removes diseased tissue, and advancement flaps cover a defect with nearby tissue. The guideline favors treatment matched to sphincter tone, previous injury and continence risk. A high average healing rate cannot remove an individual’s concern about leakage, and evidence for some tissue-preserving alternatives is less extensive or less consistent.[6]

Evidence & uncertainty

Acute fissures often improve with nonoperative care. Chronic disease can require treatment that relaxes the internal anal sphincter. Surgery can heal more reliably, but continence risks and the patient’s existing sphincter function matter. Published treatment findings should therefore be read as benefit–harm comparisons, rather than a universal sequence for every person.[5]

Selected-source overview · Independent review pending

Published questions

Is an anal fissure the same lesion as hemorrhoids?

Selected-source overview · Independent review pending. Read the evidence context.

A fissure is a tear.[1]

Evidence behind this answer

Anal fissure
agency condition or prevention explanation · 2025
Selected relevant original official page passages inspected · June 2025: tear, symptoms, bowel care and assessment