Anal fissure

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Evidence last reviewed: 15 Feb 2026

Topic last updated: 22 Dec 2023

Anal fissure causes severe pain on defecation, often described as "like passing broken glass." The pain may continue for 1 to 2 hours and can also be burning in nature.

A small amount of fresh red blood is often passed on the stool and is also seen when wiping.

On examination of the anus, there is often marked spasm of the sphincter muscles, with significant tenderness often precluding digital examination.

Initial treatment should include either topical nitroglycerin or diltiazem, along with a program of supportive care.

Resistant or chronic fissures may benefit from injection with onabotulinumtoxinA, and most cases can be cured by surgical sphincterotomy or anal advancement flap.

Definition

Anal fissure is a split in the skin of the distal anal canal characterized by pain on defecation and rectal bleeding. It is a common condition in young to middle-aged adults and may occur in 1 in 350 people.[1] It is the second commonest gastrointestinal complication of pregnancy after hemorrhoids. The pain is described as severe (often described as "like passing broken glass") and has a serious negative effect on quality of life.[2][3][4]

History and exam

Key diagnostic factors

pain on defecation
tearing sensation on passing stool
fresh blood on stool or on paper
anal spasm

Full details

Other diagnostic factors

intermittent symptoms
sentinel pile
fissure visible on retraction of buttock

Full details

Risk factors

hard stool
pregnancy
opiate analgesia

Full details

Diagnostic tests

1st tests to order

clinical diagnosis

Full details

Tests to consider

anal manometry
anal ultrasound

Full details

Treatment algorithm

ACUTE

on presentation

resistant fissures

Contributors

Authors

Nivedh Paluvoi, MD

Assistant Professor of Surgery

Colorectal Surgery

Miller School of Medicine

University of Miami

Coral Gables

Disclosures

NP declares that he has no competing interests.

Acknowledgements

Dr Nivedh Paluvoi would like to gratefully acknowledge Dr John R. T. Monson, Dr John Scholefield, and Dr Jonathan Lund, previous contributors to this topic. JRTM declares that he has no competing interests. JS and JL are authors of a number of references cited in this topic.

Peer reviewers

Stephen H. Leveson, MD, FRCS

Professor

York Hospital

York

Divulgaciones

SHL declares that he has no competing interests.

Steven Brown, MD, FRCS

Consultant Colorectal Surgeon

Northern General Hospital

Sheffield

Divulgaciones

SB declares that he has no competing interests.

Jan Rakinic, MD, FACS, FASCRS

Associate Professor of Surgery

Chief

Section of Colorectal Surgery

Southern Illinois University School of Medicine

Springfield

Divulgaciones

JR is an author of a reference cited in this topic.

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Referencias

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Artículos principales

Gilani A, Tierney G. Chronic anal fissure in adults. BMJ. 2022 Jan 12;376:e066834.

Lund JN, Nystrom PO, Coremans G, et al. An evidence-based treatment algorithm for anal fissure. Tech Coloproctol. 2006 Oct;10(3):177-80. Resumen

American Gastroenterological Association. American Gastroenterological Association medical position statement: diagnosis and care of patients with anal fissure. Gastroenterology. 2003 Jan;124(1):233-4.Texto completo

Davids JS, Hawkins AT, Bhama AR, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anal fissures. Dis Colon Rectum. 2023 Feb 1;66(2):190-9.Texto completo

Menteş BB, Irkörücü O, Akin M, et al. Comparison of botulinum toxin injection and lateral internal sphincterotomy for the treatment of chronic anal fissure. Dis Colon Rectum. 2003 Feb;46(2):232-7. Resumen

Artículos de referencia

Una lista completa de las fuentes a las que se hace referencia en este tema está disponible para los usuarios con acceso a todo BMJ Best Practice.

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Guías de práctica clínica
- Clinical practice guideline for the management of anal fissures
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მეტი Folletos para el paciente
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Anal fissure

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

on presentation

resistant fissures

Contributors

Authors

Nivedh Paluvoi, MD

Disclosures

Acknowledgements

Peer reviewers

Stephen H. Leveson, MD, FRCS

Divulgaciones

Steven Brown, MD, FRCS

Divulgaciones

Jan Rakinic, MD, FACS, FASCRS

Divulgaciones

Agradecimiento de los revisores por pares

Divulgaciones

Referencias

Artículos principales

Artículos de referencia

Una lista completa de las fuentes a las que se hace referencia en este tema está disponible para los usuarios con acceso a todo BMJ Best Practice.

Diferenciales

Guías de práctica clínica

Folletos para el paciente

შედით სისტემაში ან გამოიწერეთ BMJ Best Practice

შედით სისტემაში ან გამოიწერეთ BMJ Best Practice

შედით სისტემაში BMJ Best Practice-ის მასალებზე სრული წვდომისთვის