SHARP PAIN
Sharp or burning pain during a bowel movement.
BACK TO SERVICESACUTE & CHRONIC FISSURE · CONTINENCE-PRESERVING CARE
ANAL FISSURE: DIAGNOSIS AND INDIVIDUALISED TREATMENT
An anal fissure typically causes pain during and after a bowel movement, often with minor bleeding. Diagnosis comes before treatment, which progresses from bowel regulation and topical therapy to botulinum toxin and, in selected cases, sphincter-preserving or other surgical treatment. Assessment is available in Athens for patients from Attica and throughout Greece.
CONSERVATIVE CAREBOTULINUM TOXINTAILORED SURGERY
EXPLORE THE PROCEDURESELIXIS · ADVANCED CARE
Acute or chronic fissure: duration is not the only criterion
An acute fissure usually has symptoms for less than six weeks. A chronic fissure may have a sentinel skin tag, hypertrophied anal papilla or exposed internal sphincter fibres. The clinical findings, sphincter tone and integrity, previous childbirth or surgery, and baseline continence guide treatment selection.
SYMPTOMS
Symptoms that merit assessment
An anal fissure is a small linear tear in the anal canal. It commonly causes sharp or burning pain during a bowel movement, pain that may continue afterwards, and a small amount of bright-red blood.
PAIN AFTERWARDS
Pain or spasm may continue for minutes or hours after a bowel movement.
BRIGHT-RED BLOOD
A small amount of blood on the toilet paper or stool surface.
FEAR OF DEFECATION
Anticipated pain may lead to delayed bowel movements and worsening constipation.
IRRITATION
Itching, burning or local irritation may coexist.
SENTINEL TAG
A chronic fissure may be accompanied by a small external sentinel skin tag.
Multiple, lateral, recurrent or non-healing fissures require fuller assessment. Less commonly, they may be associated with Crohn's disease, infection or malignancy.
TREATMENTS
Treatment, step by step
Treatment begins with bowel-habit optimisation. Escalation is considered only when symptoms persist and after assessing continence risk.
BOWEL REGULATION & SYMPTOM RELIEF
Fibre, adequate fluid intake, stool softening or a gentle laxative when needed, warm baths and appropriate analgesia usually form the initial basis of treatment and are individualised to avoid both constipation and diarrhoea.
- WHEN IT MAY BE CONSIDERED
- Acute fissure and as the initial foundation in a chronic presentation.
- WHAT IT INVOLVES
- The aim is soft, formed stool without straining or prolonged toilet time. A topical anaesthetic may relieve pain but does not heal the fissure by itself.
TOPICAL GTN OR DILTIAZEM
Topical glyceryl trinitrate (GTN) or diltiazem temporarily relaxes the internal sphincter and may improve local blood flow and healing.
- WHEN IT MAY BE CONSIDERED
- Persistent acute or chronic fissure despite appropriate bowel regulation.
- WHAT IT INVOLVES
- Choice, concentration and duration require medical direction. GTN may cause headache, dizziness or hypotension and must not be combined with sildenafil, tadalafil, vardenafil or similar medicines. Diltiazem usually causes fewer headaches and may be used off-label, depending on the available preparation.
BOTULINUM-TOXIN INJECTION
Botulinum toxin temporarily relaxes the internal sphincter to reduce spasm and support healing.
- WHEN IT MAY BE CONSIDERED
- When topical treatment has not succeeded or when a reversible, sphincter-preserving option is preferred.
- WHAT IT INVOLVES
- Healing is not guaranteed. Repeat treatment may be needed, and recurrence or temporary difficulty controlling gas or stool can occur.
04FISSURECTOMY · FLAP
FISSURECTOMY & ADVANCEMENT FLAP
Fissurectomy removes chronic fibrotic tissue. In selected cases it may be combined with botulinum toxin or an advancement flap of healthy tissue.
- WHEN IT MAY BE CONSIDERED
- Chronic fibrotic or low-pressure fissure and patients at increased risk of continence disturbance after sphincterotomy.
- WHAT IT INVOLVES
- This is a sphincter-preserving strategy. Evidence is less extensive than for sphincterotomy and selection is individualised.
05TAILORED LIS
TAILORED LATERAL INTERNAL SPHINCTEROTOMY
Limited division of part of the internal sphincter reduces persistent spasm and is the most effective operation for an appropriately selected chronic fissure.
- WHEN IT MAY BE CONSIDERED
- Chronic high-tone fissure persisting despite appropriate conservative and medical treatment in a patient without increased continence risk.
- WHAT IT INVOLVES
- Division is usually tailored to the fissure apex. It is not suitable for everyone: baseline incontinence, obstetric or other sphincter injury, Crohn's disease and previous anal surgery require particular caution. There is a real risk of a temporary or persistent change in control of gas or stool; individual risk is assessed and discussed before surgery.
Conceptual anatomical artwork for general information — not a patient photograph or an exact representation of an operation.
PLANNING & SAFETY
Continence first — then procedure selection
There is no single treatment suitable for everyone. Before intervention, fissure location and chronicity, sphincter tone and integrity, previous childbirth or surgery, baseline continence and response to earlier treatment are assessed.
CORRECT DIAGNOSIS
Gentle inspection is often sufficient for the initial clinical diagnosis. Further assessment may be required, while painful digital examination or anoscopy may be deferred.
ATYPICAL FISSURE
A lateral, multiple or non-healing lesion requires assessment for an underlying condition.
CONTINENCE ASSESSMENT
A history of incontinence, obstetric injury or previous surgery materially changes safe selection.
STEPWISE CARE
Treatment progresses from bowel regulation to more invasive options only when there is a clear indication.
QUESTIONS
FREQUENTLY ASKED QUESTIONS
Short answers before an individualised surgical assessment.
01How is a fissure different from haemorrhoids?
A fissure more often causes severe sharp pain during and after a bowel movement. Haemorrhoids more often cause painless bleeding or prolapse, although they can also be painful. Examination is needed to confirm the cause.
02Can it heal without surgery?
Yes. Many acute and some chronic fissures heal with bowel regulation and topical treatment. Response is reassessed before surgery is discussed.
03When is a fissure considered chronic?
Usually when it persists for more than six weeks or has chronic features such as a sentinel tag or exposed internal sphincter fibres. Duration is not the only criterion.
04When is botulinum toxin used?
It may be considered after unsuccessful topical treatment or when temporary sphincter-preserving relaxation is preferred. Healing is not guaranteed and repeat treatment may be needed.
05When is surgery needed?
When a chronic fissure persists despite appropriate non-surgical treatment or when anatomy and symptoms require a different approach. Surgery is selected after continence assessment.
06Is there a risk of incontinence after sphincterotomy?
Yes. The risk may involve a temporary or persistent change in gas or stool control and depends on the patient's history and sphincter integrity. It is discussed individually before surgery.
07How long does recovery take?
It depends on the treatment, chronicity, bowel regulation and type of work. Individual advice is provided without guaranteeing a fixed timetable.
08Why can a fissure recur?
Hard stool, straining, diarrhoea, persistent spasm or an underlying condition can prevent healing or cause a new fissure. Long-term bowel regulation remains important.
CLINICAL EVIDENCE
CLINICAL EVIDENCE
The final choice is based on the clinical presentation, individual anatomy and current guidance.
01ASCRS · Anal Fissures Guideline 2023Clinical guideline for diagnosis and treatmentOFFICIAL SOURCE02ACPGBI · Anal Fissure Guideline 2023British and Irish guidelineOFFICIAL SOURCE03NICE · Topical diltiazemEvidence review of topical diltiazem for chronic fissureOFFICIAL SOURCE04NICE · Topical GTNEvidence review of topical GTN for chronic fissureOFFICIAL SOURCE05NHS · Anal fissurePatient information on symptoms and treatmentOFFICIAL SOURCE
This content is educational and does not replace medical assessment. No technique is appropriate for everyone; benefits, risks and alternatives are discussed individually.
INDIVIDUALISED SURGICAL ASSESSMENT
The right operation starts with the right indication.
Symptoms, investigations and alternatives are reviewed during consultation to create a safe, individualised treatment plan.
REA MED practice & directions