GPAtlas🧭 When to suspect
Suspect an anal fissure in anyone with sharp, tearing, or burning pain during and immediately after defecation. The pain is often intense and can linger for up to an hour or two afterwards, and there is usually a small amount of bright red blood on the toilet paper or on the surface of the stool. The usual trigger is the passage of a hard or bulky stool, so constipation, a recent bout of diarrhoea, pregnancy and childbirth are common precipitants. Most fissures are primary, sit in the posterior midline, and heal with simple measures.
Two distinctions drive management. The first is duration: an acute fissure has been present for less than 6 weeks, while a chronic fissure persists beyond 6 weeks and often shows a sentinel skin tag, exposed internal-sphincter fibres and a hypertrophied anal papilla. The second is whether the fissure is typical or atypical: a fissure that is off the midline (lateral), multiple, painless, large or irregular is a warning sign of a secondary cause – Crohn's disease, HIV or another infection (TB, syphilis), or malignancy – and should not be treated as a simple primary fissure.
| Feature | Acute fissure | Chronic fissure |
|---|---|---|
| Duration | < 6 weeks | ≥ 6 weeks |
| Typical appearance | Fresh, superficial tear in the anal lining | Deeper tear with a sentinel skin tag, exposed sphincter fibres and a hypertrophied papilla |
| First step | Conservative measures and simple analgesia | Conservative measures plus a topical sphincter relaxant (GTN / diltiazem) |
| Course | Most heal within 1–2 weeks | Refer to colorectal surgery if unhealed after 8 weeks of treatment |
Source: ACPGBI 2023 · NICE NG12
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