Anal Fissures: It’s painful and often mistaken for hemorrhoids

Mar 24, 2024 News

Dr. Zulfikar Bux
Emergency Medicine Specialist

A couple days ago, a patient came to my clinic who was frustrated because of his pains that he thought were coming from hemorrhoids. He wanted relief as it was so painful that he was unable to pass stool.

Anal Fissures: It’s painful and often mistaken for hemorrhoids

It was hard to convince him that hemorrhoids usually do not cause that significant amount of pain. It was not the first time I have had patients who were either being mistreated, or weren’t aware that their significant anal pains were as a result of anal fissure and not hemorrhoids. An anal fissure occurs when there is a tear in the lining of the anal canal and it is one of the most common causes of anal pains. Today, I will discuss this extremely discomforting condition and hopefully help those that may be unaware of its presentations.

What are the symptoms of anal fissures?

The most common symptom of anal fissures is pain during or after passing stool. Pain from anal fissure can cause anal muscle spasm and tightness, which worsens the problem.
Other symptoms include:

Blood on toilet paper.
tearing sensation during bowel movements
irritation or itching around the tear
A small lump or skin tag around your anus.

What are the causes of anal fissures?
Damage to the skin around your anus from over-stretching is the most common reason why an anal fissure develops. They can be caused by various factors such as:

constipation or straining during bowel movements
repeated diarrhea
pregnancy, childbirth and after delivery
sexually transmitted infections (STIs), particularly HIV, syphilis, and herpes simplex
anal intercourse
Crohn’s disease, anal cancer, tuberculosis and chemotherapy..

When a fissure develops, the muscles inside the anus go into spasm which can cause further tearing and cutting off of blood flow making healing more difficult.

How are anal fissures diagnosed?

If you have any of the symptoms above, you need to visit your doctor who will assess your symptoms and look at the skin around your anus to make a diagnosis. If there is an obvious fissure then usually a rectal exam is not required. If a fissure isn’t visible but you have bleeding, and there is no obvious haemorrhoid to explain the bleeding, then they may arrange some tests such as a colonoscopy.

How are anal fissures treated?

Most fissures can be treated simply and heal within a few weeks. Many fissures will heal on their own without medical treatment. However medical treatment increases the success rate.

Ease and prevent constipation– Soft stools will be less likely to open the fissure and cause pain. Using some fiber in your diet, drinking plenty of water, and a stool softener or a laxative, will be of significant benefit.
Avoid straining during bowel movements- You can place your legs on a short stool while on the toilet to help relax the muscles around the anus. You can also take regular sitz baths (sitting in warm water up to the hips) to ease the pain and relax these muscles.
Maintain good hygiene- It’s important to keep your anal area clean by washing gently with water after passing a bowel motion. Make sure to wipe gently after going to the toilet.
Creams or ointments– Pain relieving ointments or creams such as lidocaine will help numb the area and ease the pain. Creams or ointments such as Glyceryl trinitrate or diltiazem, relaxes the anal muscles will help relieve pain and help healing.
Botox and surgery- A surgeon could either give you an injection of Botox to relax your tight anal muscles or offer surgery. Surgery has the highest success rate of all treatments but has the highest risks and so is done as a last resort. The surgical options include making a small cut in your anal sphincter muscle (sphincterotomy), a skin flap, and cutting out the fissure. The sphincterotomy is the procedure of choice for most people needing surgery.
Are there risks if anal fissures are left untreated?

Anal fissures are not usually harmful or dangerous. However, some people, including children, may avoid having bowel movements due to fear of pain. This avoidance can lead to worsening constipation and increased straining during bowel movements, which makes the fissure worse or creates new fissures. To prevent this, it’s important to address the underlying issues and encourage regular, pain-free bowel movements. Otherwise, the fissure can become chronic and recurrent.

In rare cases, an infection or fistula can develop as a complication of an anal fissure. A fistula is an abnormal connection that forms between the inside of the rectum and the skin, creating a new channel.

If you or someone you know is suffering from anal pains, do not assume its hemorrhoids, get checked out to ensure you prevent an avoidable complication.