Symptoms

Signs and symptoms of an anal fissure include:

• Pain during bowel movements that can be severe
• Pain after bowel movements that can last up to several hours
• Bright red blood on the stool or toilet paper after a bowel movement
• Itching or irritation around the anus
• A visible crack in the skin around the anus
• A small lump or skin tag on the skin near the anal fissure

When to see a doctor See your doctor if you have pain during bowel movements or notice blood on stools or toilet paper after a bowel movement.

Causes

More common causes of anal fissure include:

• Large or hard stools passing through the anal canal
• Constipation and straining during bowel movements
• Chronic diarrhea
• Inflammation of the anorectal area, caused by Crohn's disease or another inflammatory bowel disease (IBD)

Less common causes of anal fissures include:

• Anal sex
• Cancer
• HIV
• Tuberculosis
• Syphilis

Risk factors

Factors that may increase your risk of developing an anal fissure include:

• Infancy. Many infants experience an anal fissure during their first year of life, although experts aren't sure of the reason.
• Aging. Older adults may develop an anal fissure partly because of slowed circulation, resulting in decreased blood flow to the rectal area.
• Constipation. Straining during bowel movements and passing hard stools increase the risk of tearing.
• Childbirth. Anal fissures are more common in women after they give birth.
• Crohn's disease. This inflammatory bowel disease causes chronic inflammation of the intestinal tract, which may make the lining of the anal canal more vulnerable to tearing.

Complications

Complications of anal fissure can include:

• Anal fissure that fails to heal. An anal fissure that doesn't heal can become chronic, meaning it lasts for more than six weeks.
• Anal fissure that recurs. If you've experienced anal fissure once, you have an increased risk of another anal fissure.
• A tear that extends to surrounding muscles. An anal fissure may extend into the ring of muscle that holds your anus closed (internal anal sphincter). This makes it more difficult for your anal fissure to heal. An unhealed fissure may trigger a cycle of discomfort that may require medications or surgery to reduce the pain and repair or remove the fissure.

Appointment

If you have an anal fissure, you're likely to start by seeing your family doctor or a general practitioner. You may be referred to a gastroenterologist or a colon and rectal surgeon.

Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions can help you make the most of your time together. List your questions from most important to least important, in case time runs out. For anal fissure, some basic questions to ask your doctor include:

• What is likely causing my symptoms?
• Are there any other possible causes for my symptoms?
• Do I need any tests?
• Is my condition likely temporary (acute) or chronic?
• What treatments do you recommend?
• Are there any dietary suggestions I should follow?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment anytime you don't understand something.

What to expect from your doctor Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to spend more time on. Your doctor may ask:

• When did you first begin experiencing symptoms?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Do you have any other medical conditions, such as Crohn's disease?

What you can do in the meantime While you're waiting to see your doctor, take steps to avoid constipation. This may include drinking plenty of water, adding fiber to your diet and exercising regularly. Also, avoid straining during bowel movements. The extra pressure may lengthen the fissure or create a new one.

Tests and diagnosis

Your doctor will likely ask you for your medical history and perform a physical exam, including inspection of the anal region. Often the tear is visible. Usually this is all that's needed to diagnose an anal fissure.

Your doctor may refrain from performing a rectal exam, which involves inserting a gloved finger into your anal canal, because it may be too painful. In some cases, however, your doctor may use a short, lighted tube (anoscope) to inspect your anal canal and see how far an anal fissure extends.

If your signs and symptoms suggest you might have an underlying disorder such as Crohn's disease or colorectal cancer, your doctor may recommend further testing:

• Flexible sigmoidoscopy. This test involves inserting a thin, flexible tube with a tiny video camera into the bottom portion of your colon. Flexible sigmoidoscopy may be done if you're younger than 50 and have no risk factors for intestinal diseases or colon cancer.
• Colonoscopy. In this test, the tube allows viewing of your entire colon. If you're 50 or older, your doctor likely will recommend a colonoscopy, which also screens for colon cancer.
• Anal manometry. In this test, your doctor inserts a narrow, flexible tube into your anus and rectum. Once the tube is in place, a small balloon at the tip of the tube may be expanded. This test lets your doctor know how tight your anal sphincter is. It also measures the sensitivity and function of your rectum.

Treatments and drugs

Anal fissures often heal within a few weeks if you take steps to keep your stools soft and treat constipation or diarrhea. If the tear doesn't heal within six to eight weeks, however, you'll likely need medical treatment or possibly surgery.

If your infant has been diagnosed with an anal fissure, change your child's diaper regularly and keep the anal area clean. Ask your child's pediatrician about strategies to prevent constipation and ways to keep your child from straining during bowel movements.

Nonsurgical treatments If lifestyle and self-care measures — including adding more fiber to your diet, drinking more water, getting regular exercise and taking a stool softener — aren't effective, your doctor may recommend the following nonsurgical treatments:

• Fiber supplements. Taking a regular fiber supplement will help keep your stool soft and easier to pass, to avoid further irritation of the fissure.
• Sitz baths. Soaking in warm water for 10 to 20 minutes several times a day, especially after bowel movements, will help relax the sphincter and promote healing. Don't use soap or bubble bath, as this may irritate the area.
• Medicated creams. Your doctor may suggest a rectal cream or ointment (Anusol-HC, zinc oxide, others) to help relieve discomfort from a mild fissure.
• Nitrogylcerin. Applying nitroglycerin ointment to the anus widens blood vessels and increases blood flow to the fissure, promoting healing. This therapy also helps reduce pressure in the anal sphincter, which eases the spasm and decreases pain. Side effects may include headaches, low blood pressure and dizziness. Your doctor may advise you to wear a disposable glove while applying nitroglycerin ointment, to remain seated or lying down, and to avoid exercise immediately afterward, to minimize side effects. Men shouldn't use nitroglycerin within 24 hours of taking erectile dysfunction medications, such as sildenafil (Viagra), tadalafil (Adcirca, Cialis) and vardenafil (Levitra), because of the possibility of significantly lowered blood pressure. You'll probably have to have nitroglycerin ointment custom formulated at a compounding pharmacy.
• Botox. Injecting a small dose of onabotulinumtoxinA (Botox) into the anal sphincter paralyzes the muscle for several months, causing the spasm to relax. Possible side effects include pain at the injection site or temporary, mild leakage of gas or stool (anal incontinence).
• Calcium channel blockers. The blood pressure medications nifedipine (Adalat) and diltiazem (Cardizem), taken orally or ground into a gel and applied to the fissure, also may help.

Surgery If you have a chronic anal fissure that hasn't healed with other treatments, your doctor may recommend surgery. Surgery involves cutting a small portion of the anal sphincter muscle to reduce spasm and pain and promote healing. Surgery is usually done on an outpatient basis.

Home remedies

Several lifestyle changes may help relieve discomfort and promote healing of an anal fissure, as well as prevent recurrences:

• Add fiber to your diet. Getting enough fiber in your diet — about 25 to 30 grams a day — improves fissure healing and helps keep stools soft. You can increase your fiber intake by eating more fruits, vegetables, nuts and whole grains. Bulk-forming laxatives, such as psyllium (Metamucil, others), soften stools and allow them to pass more easily. Adding fiber through either diet or supplementation may cause gas and bloating, so increase your fiber intake gradually.
• Drink adequate fluids. Fluids also help prevent constipation, so it's important to get enough. If you're rarely thirsty and your urine looks colorless or only very light yellow, you're probably drinking enough.
• Exercise regularly. Engage in 30 minutes or more of moderate physical activity, such as walking, most days of the week. Exercise promotes regular bowel movements and increases blood flow to all parts of your body, which may promote healing of an anal fissure.
• Avoid straining during bowel movements. Straining creates pressure, which can open a healing tear or cause a new tear.

Prevention

You may be able to prevent an anal fissure by taking measures to prevent constipation. Eat high-fiber foods, drink fluids and exercise regularly to keep from having to strain during bowel movements.