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Anal Fissure

An anal fissure is a very common condition. It is a small tear in the lining (mucosa) of the anal canal.

Patients with an anal fissure typically experience:

  • severe pain during bowel movements

  • burning or sharp pain that can last minutes to hours afterward

  • fear of the next bowel movement

  • occasionally bright red blood on the toilet paper

If pain during and shortly after a bowel movement is intense, this is highly suggestive of an anal fissure.

 

Where Do Fissures Usually Occur?

Most fissures occur in one of two typical locations:

  • posterior (back) midline

  • anterior (front) midline

These locations are common because they are areas of relatively reduced blood supply, making healing more difficult once a tear has occurred.

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How Does a Fissure Develop?

In most cases, fissures start from mechanical injury, such as:

  • passing a hard stool

  • constipation

  • straining

  • diarrhea with frequent wiping

This causes a small tear in the anal lining.

Unfortunately, once a fissure forms, a vicious cycle often develops:

  1. A tear occurs in the anal lining

  2. Severe pain causes the anal sphincter muscle to go into spasm

  3. The spasm prevents normal opening of the anus

  4. Blood flow to the area is reduced

  5. Healing becomes difficult

  6. Pain causes fear of bowel movements

  7. Patients delay bowel movements

  8. Stool becomes harder

  9. Further tearing occurs

This is why fissures can become chronic and long-standing.

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Why Fissures Can Persist

Because of muscle spasm and poor blood flow, fissures often do not heal on their own, even though the tear itself is small.

Many patients suffer for months — sometimes years — unless the cycle is properly interrupted.

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Assessment in the Office

When a patient is referred for fissure symptoms:

  • A careful external examination is performed

  • If an active or painful fissure is seen, an internal examination is often not performed, as this may be extremely painful and may worsen the fissure

  • In selected cases, an internal examination may be done if clinically appropriate

The diagnosis is usually clinical.

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Treatment Approach

Treatment is usually stepwise, beginning with medical (non-surgical) therapy.

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1. Conservative (Medical) Management

Approximately 50% of patients improve with medical treatment alone.

This includes:

  • Aggressive fibre supplementation

  • Maintaining soft, regular bowel movements

  • Avoiding straining

  • Adequate hydration

Soft stool is one of the most important components of healing.

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2. Topical Nifedipine Cream

If symptoms persist, I commonly prescribe topical nifedipine cream.

Although nifedipine is a blood pressure medication, when used as a cream it:

  • relaxes the anal sphincter

  • reduces spasm

  • improves blood flow

  • allows healing of the fissure

This treatment is well supported in the medical literature and is generally very well tolerated.

  • About 50% of patients respond to standard dosing

  • An additional 20% may respond to higher-dose therapy

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3. Botox (Chemical Sphincterotomy)

If medical therapy fails, the next step is often Botulinum toxin (Botox) injection.

Botox works by:

  • temporarily relaxing the anal sphincter

  • improving blood supply

  • allowing healing without permanent muscle damage

This treatment is generally safe and reasonably effective.

 

4. Surgery (Lateral Internal Sphincterotomy)

Approximately 10% of patients do not respond to medical or Botox therapy.

In these cases, surgery may be considered.

A lateral internal sphincterotomy involves dividing a small portion of the internal anal sphincter to permanently relieve spasm.

While this procedure is highly effective, it does carry a risk of fecal incontinence, particularly for gas or minor leakage.

For this reason, surgery is considered a last resort.

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Pain Control and Supportive Care

In addition to fissure-specific treatment, supportive measures may include:

  • fibre supplementation

  • stool softeners

  • adequate fluid intake

  • short-term anti-inflammatory medication if appropriate

The goal is always to reduce pain, prevent spasm, and allow healing.

 

Final Thoughts

Anal fissures are common, painful, and frustrating — but they are very treatable.

Most patients improve without surgery when treatment is followed consistently.

Early treatment significantly improves outcomes and reduces the risk of chronic disease.

If symptoms persist despite conservative therapy, further options can be discussed in a structured and stepwise manner.

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