An anal fissure is a common and painful condition that significantly affects a patient’s daily life. It is essentially a small tear in the inner lining of the anus, accompanied by pain, bleeding, and severe discomfort, especially during bowel movements. Most fissures are caused by the passage of hard or bulky stools due to constipation or other factors that increase pressure in the anal area. In the acute phase, most fissures heal within a few weeks if treated promptly and properly. However, in many cases, the tear does not fully heal, leading to the development of a chronic anal fissure.
What is a chronic anal fissure?
A chronic anal fissure is a tear—essentially a small crack—in the inner lining of the anus that lasts for more than six to eight weeks and displays specific characteristics such as hardened edges, a small skin tag, and reduced blood supply to the area.
The reason an anal fissure does not heal and becomes chronic is mainly related to the spasm of the internal anal sphincter. This is an internal muscle that normally helps control bowel movements. In cases of fissure, this muscle contracts excessively and remains in a constant state of spasm, reducing blood flow and preventing the tear from healing. This creates a vicious cycle: pain causes spasm, spasm reduces blood circulation, and the reduced blood supply delays healing—ultimately resulting in a chronic anal fissure that does not resolve.
Risk factors
There are many factors that can cause or contribute to the development and chronicity of an anal fissure. Constipation and repeated straining during bowel movements are the most common ones. Frequent diarrhea, childbirth, injuries, inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis, as well as increased muscle tone in the area, can also promote the occurrence and persistence of the condition. Additionally, factors like age, the patient’s overall health, stress, and poor dietary habits can significantly influence the course of the fissure.
Symptoms caused by a chronic anal fissure
The symptoms caused by a chronic anal fissure are characteristic and usually intense. Pain during bowel movements is the primary symptom and often persists for hours afterward. Patients typically describe a sharp, burning pain. Mild bleeding is also common, with bright red blood appearing on the toilet paper or on the surface of the stool. Other symptoms may include itching, irritation in the area, a sensation of tightness, or even difficulty with bowel movements due to fear of the pain. In more advanced cases, a small skin tag may be visible at the anal opening.
Treatment options and duration for a chronic anal fissure
The initial therapeutic approach is based on conservative treatment, aiming to reduce pain, prevent constipation, and relax the sphincter. The patient is advised to follow a diet rich in fiber and fluids to ensure soft stool consistency. The use of mild stool softeners is often very helpful. Taking warm sitz baths several times a day provides relief and promotes sphincter relaxation. In addition, topical ointments—such as those containing nitroglycerin or calcium channel blockers (diltiazem, nifedipine)—help improve blood flow and facilitate healing. In some cases, topical anesthetics are also prescribed to provide immediate pain relief.
In more persistent cases, or when conservative treatment fails to produce results within a reasonable timeframe, alternative methods are employed—such as the injection of botulinum toxin into the internal anal sphincter. This injection causes temporary relaxation of the sphincter, reducing pain and allowing the fissure to heal. Its effect lasts for several months and is often sufficient for complete recovery.
For more resistant or recurrent chronic fissures, surgical intervention is recommended. The most common procedure is lateral internal sphincterotomy, in which a partial incision is made in the internal sphincter to reduce spasm and restore blood flow. This surgery is simple and highly effective, with success rates exceeding 90%.
Of course, there is also a more modern and painless method which is the anal fissure laser treatment. Laser surgery for anal fissures is one of the most effective techniques for the definitive cure of the condition. This specific technique is preferred because the special laser fiber is used to clean the fissure and effectively relieve symptoms, while leaving the anal sphincter muscle untouched.
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Recovery time
The time required for the complete healing of an anal fissure depends on several factors. The severity and chronicity of the fissure, the patient’s overall health, age, adherence to treatment instructions, and the chosen therapeutic method all influence the duration of recovery.
In general, acute fissures, when treated promptly, heal within two to four weeks. In contrast, a chronic anal fissure—even with the best conservative treatment—may take several weeks or even months to fully heal. If the condition does not improve after three months of treatment, more aggressive intervention is usually necessary.
It’s important to note that patients who carefully follow medical advice, adopt a healthy diet, drink adequate amounts of water, and avoid straining during bowel movements tend to achieve significantly better outcomes.
Prevention strategies
The prevention of an anal fissure is based on avoiding the factors that cause it. A proper diet rich in dietary fiber, good hydration, regular physical activity, and avoiding excessive straining during bowel movements are all highly beneficial. Additionally, for individuals with a history of fissures or increased sensitivity in the area, timely management of any episodes of constipation or diarrhea can help prevent the development of a new fissure.
In any case, if symptoms persist for more than six weeks, or if the pain and bleeding are severe and affect quality of life, it is important for patients to consult a specialized surgeon. Modern treatment options can provide relief even in the most challenging cases, such as when a chronic anal fissure is present. The General Surgeons in Athens who make up the Colon Rectal team treat each case of anal fissure using the most appropriate therapeutic method based on the individual needs of the patient.
