Anal Fissure: Why It Hurts So Much and How It Heals Without Surgery

Medically reviewed by Dr Murlidhar Boob — MS, FAIS, DLS, FMAS, Laparoscopic Surgeon & Surgical Gastroenterologist, Shubham Hi-Tech Hospital & Test Tube Baby Centre, Amravati.

Some patients describe it as passing broken glass. Others say it feels like a hot knife that stays for an hour after they leave the toilet. Then they hear that the cause is a tear “smaller than a grain of rice”, and they don’t quite believe it. I understand why. An anal fissure is one of the smallest problems I treat and one of the most painful, and that mismatch is exactly what makes people frightened of going to the toilet.

The good news is that most fissures heal without any operation. The less good news is that they heal best when you understand what is keeping them open.

What a fissure actually is

An anal fissure is a split in the delicate skin just inside the anus. It usually starts when a hard or very large stool stretches that skin too far. Sometimes it follows a bout of diarrhoea, where repeated, forceful passage does the same damage. It can also appear after childbirth.

The tear itself is not what makes the pain linger. Underneath that skin sits a ring of muscle, the internal sphincter. When the tear is touched by stool, this muscle goes into spasm and stays tight for a while. The spasm pulls the edges of the tear apart, squeezes the small blood vessels that would otherwise feed the healing skin, and keeps the pain going long after the motion is over. So a small tear becomes a cycle: pain, spasm, poor blood flow, no healing, more pain.

If you want to understand how this differs from piles, I have written about that separately in Are piles serious? When you should see a surgeon. I won’t repeat the piles grading here.

“Doctor, I’m so scared of the pain that I’ve started holding it in. Is that wrong?”

It is the single most common thing I hear, and yes, it backfires. Holding on makes the stool drier and harder, so the next motion tears the area again. Break the cycle instead: soften the stool first, then go when you feel the urge. A fissure is far kinder to a soft stool passed on time than to a hard one that has been put off.

What helps it heal

Think of treatment as three jobs: keep the stool soft, relax the muscle, and give the skin a chance.

• Fibre and fluids. More fruit, vegetables, whole grains and plenty of water through the day. A bulk-forming fibre supplement or a gentle stool softener can help if food alone isn’t enough.
• Warm sitz baths. Sitting in a few inches of warm water for 10 to 15 minutes, especially after a motion, relaxes the sphincter and eases the pain.
• Don’t strain, don’t linger. Go when you feel the urge and leave when you are done. No phone, no waiting.
• Medicated ointments. If the fissure doesn’t settle in a couple of weeks, we often prescribe an ointment that relaxes the sphincter, which restores blood flow to the tear. Some people get a headache with certain ointments, so tell us if that happens. A local anaesthetic gel can take the edge off the pain in the meantime.

A fissure that began recently usually responds well to this. Once it has lasted more than six to eight weeks, we call it chronic, and it behaves differently. The edges become thickened, and you may notice a small skin tag at the outer end, often called a sentinel pile, or a small fleshy bump inside. These are signs the fissure has been open a while.

What to expect at your appointment

You may be dreading the examination more than anything else, so here is how it goes. We start by talking: how long, how painful, your bowel habits, any childbirth or diarrhoea history. Then comes a gentle look at the area. In many cases a fissure can be seen just by parting the skin, and if it is very painful we won’t push an internal examination that day; we will treat the pain first. If there is anything unusual about the fissure, we may plan a closer check under comfortable conditions. You will leave with a clear plan, usually starting with diet, baths and an ointment.

A quick self-check: when to stop waiting

See a surgeon if any of these apply:

• Pain with every motion that has lasted more than a few weeks
• Bleeding that continues, or a lot of blood rather than a streak on the tissue
• A fissure that heals and keeps coming back
• A tear that is not at the usual spot (the back or sometimes the front midline) or that sits off to the side
• More than one fissure, or any discharge, fever or swelling near the anus
• Long-standing diarrhoea, weight loss, or a known bowel condition

A fissure in an unusual place, or one that refuses to heal, is the sort of thing we like to look at properly. Occasionally it points to another cause such as inflammatory bowel disease, and that needs its own investigation. For the common, ordinary fissure, though, none of this applies.

Myth versus fact

Myth: A fissure needs surgery. Fact: Most acute fissures, and many chronic ones, heal with softening the stool, sitz baths and ointments.

Myth: Spicy food caused it. Fact: It can irritate, but the usual trigger is a hard stool or diarrhoea. Fixing the stool matters more than the chilli.

Myth: Surgery means a long, painful recovery. Fact: When an operation is needed, it is a short procedure that relaxes the tight muscle, and most people are home the same day or the next.

When an operation is reasonable

If a chronic fissure hasn’t healed despite a proper trial of treatment, or keeps returning, a procedure to relax the sphincter muscle can break the cycle for good. Your surgeon will explain the options, the benefits and the small risks, and the decision is yours. We would always rather you tried the gentler route first and came to surgery only if it is truly needed.

Don’t suffer in silence

Fissure pain is miserable, but it is one of the more treatable problems in surgery. If you are dreading the toilet, the surgical team at Shubham Hi-Tech Hospital & Test Tube Baby Centre in Amravati will be glad to see you, work out what is going on and get you comfortable again. You can call +91-8668954915 or contact us here. For the wider range of what we treat, see our general surgery and gastroenterology page.

Disclaimer: This article is for general information only and is not a substitute for professional medical advice. Please consult a qualified doctor for guidance specific to your situation.