Fissure Treatment
Management of a painful tear in the anal lining, with treatment chosen according to severity and duration
What is fissure treatment?
A fissure is a tear in the lining of the anal canal, usually at the back, and usually started by one hard stool. The tear itself is small. What makes it a condition and not a scratch is what happens next.
The muscle around the anal canal goes into spasm when the tear is stretched. The spasm squeezes the small vessels that supply the lining, so the area gets less blood exactly where it needs more, and the tear cannot heal. Passing stool re-opens it, that causes more spasm, and the cycle holds itself in place. This is why a fissure hurts far more than its size suggests, and why the pain often lasts for hours after you have finished.
A fissure of a few weeks is called acute and most heal. One that has been there for six weeks or more is chronic: the edges harden, a small tag of skin forms at the outer end, and it stops responding to stool softeners alone. Almost every treatment for it is aimed at the spasm and not at the tear.
What you might notice
- Pain or itching around the anus
- Bleeding when passing stool
How it is diagnosed
A doctor can usually diagnose a fissure by parting the skin at the anus and looking. The tear is visible at the back in most people, and the sentinel tag over it is what tells them it has been there a while.
They will not normally push a finger or an instrument in at the first visit if the pain is severe. A fissure in spasm makes that unbearable, and there is nothing to be gained. Expect a proper internal examination once the pain has settled on treatment.
A fissure in an unusual position, more than one, or one that will not heal on correct treatment makes a doctor look further. Fissures away from the midline can be a sign of Crohn's disease, infection or other conditions, and are investigated instead of simply treated again.
Recovery
On ointment and fibre, expect the pain to ease within a week or two and the tear to close over six to eight weeks. The ointment often causes a headache in the first few days; it is the drug working on blood vessels elsewhere, it fades, and it is not a reason to stop.
After a Botox injection the spasm eases over several days and the effect lasts about three months, which is the window the tear heals in. After a sphincterotomy the relief is usually immediate, because the spasm is released on the table. Most people are back to work within a few days and the fissure is healed within three to four weeks.
Sitz baths, which means sitting in warm water for ten minutes two or three times a day, genuinely help at every stage and cost nothing. Keeping stool soft is not a temporary measure: a fissure that healed will tear again on the next hard stool.
If it is left untreated
An acute fissure often heals on its own if the constipation behind it is dealt with. Left with the constipation, it usually does not.
A long-standing fissure costs quality of life and not safety. People start avoiding the toilet because of the pain, which makes the stool harder, which tears it again, and the fear becomes part of the problem. Some go years like this.
The other consequence is that the options narrow. A fissure treated early responds to ointment; one that has hardened usually needs a procedure. And a chronic fissure can develop a tract alongside it that turns into a fistula, which is a bigger problem than the one it started as.
Questions about fissure treatment
Why does it hurt for hours after I have finished?
The pain is muscle spasm and not the tear itself. Passing stool stretches the tear, the internal sphincter clamps down in response, and that spasm can last for an hour or more. It is also what stops the fissure healing: the squeezed muscle cuts off the blood supply to the exact spot that needs it. Almost every treatment offered is aimed at releasing the spasm, so the pain usually settles well before the tear has closed.
Will a sphincterotomy affect my control?
This is the right question to ask, and your surgeon should answer it specifically for you. The operation divides a small, measured part of the internal sphincter, the involuntary muscle, and leaves the external muscle you consciously control intact. Most people notice no change. A minority report some difficulty controlling wind, and a smaller number some soiling, which usually settles. The risk is higher if you have had previous anal surgery or obstetric injury, and in that situation a Botox injection is often offered instead.
Can I just use the ointment and leave it?
For a fissure of a few weeks, that is exactly the right plan, and most heal on it. Give it six to eight weeks alongside a genuinely high-fibre diet, not a few days. If it has not healed by then the edges have usually hardened and ointment alone will not close it, and continuing indefinitely mostly delays the treatment that would work. Come back at that point instead of repeating the prescription.
Other proctology treatments
Treatment for swollen veins in the anus or lower rectum, ranging from lifestyle measures to minimally invasive or surgical care
Day CareTreatment of an abnormal tunnel between the anal canal and nearby skin, usually requiring specialist assessment
Day CareTalk to a care coordinator about fissure treatment
Leave a number and a care coordinator calls you back with what the treatment involves and which hospital it would be at. They book a consult only if you want one