Understanding fissure treatment
An anal fissure is a tear in the thin lining of the anal canal. It is small — often only a few millimetres — but it sits in one of the most nerve-rich areas of the body, which is why the pain is out of all proportion to its size.
Patients describe it consistently: a sharp, tearing pain while passing stool, as if passing broken glass, followed by a deep burning ache that can last for hours afterwards. There is usually a small amount of bright red blood on the paper. The pain leads people to avoid going to the toilet, which makes the stool harder, which tears the fissure again. That cycle is the central problem.
There is a second, mechanical part to the cycle. Pain causes the internal anal sphincter to go into spasm. A tight sphincter reduces blood flow to the fissure, and a wound with poor blood supply cannot heal. This is why a fissure that has been present for more than six to eight weeks — a chronic fissure — often will not heal on diet and creams alone, no matter how disciplined the patient is.
Treatment therefore works on both fronts: keep the stool soft, and relax the sphincter. The great majority of acute fissures heal with medical treatment within a few weeks. For chronic fissures, a short day-care procedure that permanently releases a small portion of the internal sphincter, or a laser sphincterotomy, has a cure rate well above ninety percent.
Types & classification
Present for less than six weeks. A fresh, shallow tear that heals in most patients with medication and stool softening.
Present beyond six to eight weeks. The edges become fibrous, a sentinel skin tag forms outside and a hypertrophied papilla inside. Rarely heals without a procedure.
The commonest site, in the midline at the back of the anal canal, where blood supply is naturally poorest.
More frequent in women, particularly after childbirth. Needs careful assessment before any sphincter procedure to protect continence.
Fissures away from the midline, or several at once, raise the possibility of Crohn’s disease, tuberculosis or infection, and are investigated rather than simply operated on.
Symptoms & causes
Symptoms to look for
- Sharp, cutting pain during defaecation
- A burning ache continuing for minutes to hours afterwards
- A streak of bright red blood on the stool or paper
- Fear of passing stool, leading to deliberate postponement
- Spasm and tightness in the anal region
- Itching or irritation around the anus
- A small skin tag at the anal verge in long-standing cases
- Constipation worsening as the patient avoids the toilet
Common causes & risk factors
- Passing a hard, large stool — the commonest trigger
- Chronic constipation and straining
- Persistent diarrhoea and repeated wiping
- Childbirth, particularly with a difficult delivery
- A tight internal anal sphincter with reduced blood supply to the posterior midline
- A low-fibre diet and inadequate fluid intake
- Inflammatory bowel disease such as Crohn’s
- Rarely, infection including tuberculosis or sexually transmitted infection
When to see a surgeon
- Anal pain on passing stool lasting more than a week
- Pain with bleeding that keeps returning despite laxatives
- A fissure that has not healed after six to eight weeks of proper medical treatment
- Pain associated with discharge or swelling, suggesting an abscess or fistula
- Any change in bowel habit, weight loss or a family history of bowel cancer alongside bleeding
How it is diagnosed
Gently parting the buttocks usually reveals the fissure directly. In a very painful fissure, examination is kept deliberately brief.
Assesses sphincter tone. Often deferred at the first visit if pain is severe, and performed once the acute pain has been treated.
Done once comfortable, to check for coexisting piles or a fistula — a common combination.
For a very painful or atypical fissure, this allows a complete and painless assessment before deciding on treatment.
Considered when fissures are atypical, multiple, recurrent, or where inflammatory bowel disease is suspected.
Treatment options
The appropriate option depends on your diagnosis, examination and general health. Your clinician will explain the benefits and risks of the available approaches.
The foundation. High fibre, two to three litres of water daily, and warm sitz baths two to three times a day — the warmth genuinely relaxes the sphincter and relieves pain.
Keeping stool soft breaks the tear-and-spasm cycle and allows the fissure to heal. Continued for several weeks after symptoms settle.
Glyceryl trinitrate or diltiazem ointment applied to the anal canal relaxes the internal sphincter chemically and improves blood flow. Heals many acute fissures within six to eight weeks.
A temporary chemical relaxation of the sphincter lasting around three months. Useful where a permanent sphincter division is best avoided, such as in some women with an anterior fissure.
The standard curative operation for a chronic fissure. A small, calculated portion of the internal sphincter is divided away from the fissure, releasing spasm permanently. Cure rates exceed ninety-five percent and pain relief is usually immediate.
Achieves the same release using a laser fibre, with less bleeding and a smaller wound. Suitable for selected patients.
For complex or recurrent fissures where sphincter division carries too high a risk to continence, the fibrous edges are excised and healthy tissue advanced to cover the defect.
Preparing for treatment
- Begin a high-fibre diet and stool softeners before the procedure date
- Standard blood tests, ECG and anaesthetic review
- An enema on the morning of surgery, as advised
- Six hours fasting before anaesthesia
- Arrange for someone to accompany you home
- Bring details of ointments and medication already tried — it guides the choice of procedure
The procedure, step by step
- AnaesthesiaA short spinal or general anaesthetic. The procedure itself is brief.
- Examination under anaesthesiaWith the sphincter relaxed, the fissure is assessed properly and any coexisting piles or fistula identified.
- Sphincter divisionA small, carefully measured portion of the internal sphincter is divided laterally — away from the fissure itself — through a tiny incision or with a laser fibre.
- Fissure managementThe sentinel tag and any hypertrophied papilla are trimmed, and the fibrous edges of a chronic fissure are freshened so it can heal.
- DressingA light dressing. No packing is required, and the small lateral wound heals over one to two weeks.
- RecoveryObservation for a few hours until you pass urine, then discharge with painkillers, a laxative and clear instructions.
Recovery timeline
- Day 0Most people notice the characteristic fissure pain is already gone when they wake. Home the same evening.
- Days 1 – 3Mild soreness at the small lateral wound. Sitz baths after each motion. Stool softeners continued strictly.
- Days 3 – 7Return to desk work for most patients. The fissure itself begins visibly healing.
- Weeks 2 – 4The fissure and the lateral wound heal completely. Follow-up review in this period.
- Beyond 6 weeksContinue fibre and fluids. This is what prevents a new fissure forming — the operation fixes the current one, diet prevents the next.
Benefits of this approach
- Immediate and usually permanent relief from the pain cycle
- Day-care procedure with no overnight stay
- Cure rate above ninety-five percent for chronic fissure
- Small lateral wound rather than a wound at the painful fissure site
- Return to work within a few days
- Coexisting piles or fistula can be treated in the same sitting
- Breaks the constipation-fear-constipation cycle that keeps the fissure going
Risks & possible complications
Every operation carries risk, and you should hear about it before you consent rather than afterwards. These are discussed individually at consultation in the context of your own health.
- Temporary difficulty controlling flatus in a small percentage of patients
- Minor bleeding or infection at the lateral wound
- Delayed healing, more likely in smokers and uncontrolled diabetics
- Recurrence, uncommon, but more likely if constipation returns
- Rarely, minor soiling — the reason sphincter division is measured carefully and avoided in high-risk patients
What affects the cost
- Whether medical management alone or a surgical procedure is needed
- Conventional lateral sphincterotomy versus laser
- Treatment of coexisting piles or fistula in the same sitting
- Type of anaesthesia and day-care charges
- Investigations, including colonoscopy where indicated
- Covered by most insurance policies as a day-care procedure