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Anal Fissure

(Fissure in Ano; Anal Ulcer)

by Parswa Ansari, MD

An anal fissure is an acute longitudinal tear or a chronic ovoid ulcer in the squamous epithelium of the anal canal. It causes severe pain, sometimes with bleeding, particularly with defecation. Diagnosis is by inspection. Treatment is local hygiene, stool softeners, topical measures, and sometimes botulinum toxin injection and/or a surgical procedure.

(See also the American Gastroenterological Association’s technical review and medical position statement on the diagnosis and care of patients with anal fissure.)

Anal fissures are believed to result from laceration by a hard or large stool or from frequent loose bowel movements. Trauma (eg, anal intercourse) is a rare cause. The fissure may cause internal sphincter spasm, decreasing blood supply and perpetuating the fissure.

Symptoms and Signs

Anal fissures usually lie in the posterior midline but may occur in the anterior midline. Those off the midline may have specific etiologies, particularly Crohn disease. An external skin tag (the sentinel pile) may be present at the lower end of the fissure, and an enlarged (hypertrophic) papilla may be present at the upper end.

Infants may develop acute fissures, but chronic fissures are rare. Chronic fissures must be differentiated from cancer, primary lesions of syphilis, TB, and ulceration caused by Crohn disease.

Fissures cause pain and bleeding. The pain typically occurs with or shortly after defecation, lasts for several hours, and subsides until the next bowel movement. Examination must be gentle but with adequate spreading of the buttocks to allow visualization.


  • Clinical evaluation

Diagnosis is made by inspection. Unless findings suggest a specific cause or the appearance and/or location is unusual, further studies are not required.


  • Stool softeners

  • Protective ointments, sitz baths

  • Nitroglycerin ointment, topical Ca channel blocker, or botulinum toxin type A injection

(See also the Cochrane review abstract: nonsurgical and surgical therapy for anal fissure.)

Fissures often respond to conservative measures that minimize trauma during defecation (eg, stool softeners, psyllium, fiber). Healing is aided by use of protective zinc oxide ointments or bland suppositories (eg, glycerin) that lubricate the lower rectum and soften stool. Topical anesthetics (eg, benzocaine, lidocaine) and warm (not hot) sitz baths for 10 or 15 min after each bowel movement and as needed give temporary relief.

Topical nitroglycerin 0.2% ointment, nifedipine cream 0.2%, 2% diltiazem gel, and injections of botulinum toxin type A into the internal sphincter relax the anal sphincter and decrease maximum anal resting pressure, allowing healing. When conservative measures fail, surgery (internal anal sphincterotomy or controlled anal dilation) is needed to interfere with the cycle of internal anal sphincter spasm.

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