A fissure is a tiny tear in the skin. Anal fissures are usually caused by trauma, such as constipation with hard stools, rectal sex, bouts of diarrhea, or childbirth. Some patients may have fissures from underlying illness, like Crohn Disease, rectal STDs, and others.
The main symptom is anal pain, especially with bowel movements. There may be small spots of blood on the stool, but probably not large amounts. Patients often think they have “hemorrhoids,” but only because they’ve never heard of fissures. Hemorrhoids are completely different.
Diagnosis is not difficult if clinicians consider the possibility, based on symptoms and an apparently normal anus when first looking at it. Then it’s important to make sure the patient is completely relaxed, while searching point by point for a spot that’s uniquely tender. Then we carefully spread the anal skin there, to seek a bright red bleeding point. It’s crucial to have good lighting, often requiring an assistant to direct it. Sometimes exam is too uncomfortable, so we assume there’s a fissure if we find one specific point of tenderness.
Treatment aims at avoiding constipation, often by softening stools (even if they’re not hard), but avoiding anything that might cause diarrhea. Sitz baths are a mainstay: patients should sit in warm water for 5-10 minutes, at least a few times a day, even every hour if they feel like it. They shouldn’t fill a bathtub, because the aim is to only immerse the anus, to concentrate the heat there (this draws blood to the area, to facilitate healing).
Some patients benefit from prescriptions of nitroglycerine ointment. The ones for heart disease are cheap, those for fissures are expensive. Prescribers can request the pharmacist to dilute the first kind. Some patients need surgery, which works well, but unfortunately can’t be repeated more than once.
Best of all is to prevent anal fissures. This is hardest for people who greatly enjoy anal sex, because it means a significant intrusion on their lifestyle and satisfaction. We make the recommendation because it’s medically sound, but have to understand its implications.