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
• 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.
• An atypical fissure 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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