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What is an anal fissure?
An anal fissure is a small tear in the lining of the anal canal, sitting in skin full of nerve endings, which is why it hurts out of all proportion to its size. Most are made by a hard or large stool, some by diarrhea, childbirth or straining. Dr. Ihab Herraka provides anal fissure treatment at our Fort Smith Main Clinic, and most fissures heal without surgery. Fissures are routinely mistaken for hemorrhoids and treated as such for months, which is one reason they turn up so often among the lower GI conditions we see. The reason a fissure lingers is a loop: pain makes the anal muscle clamp down, and the clamped muscle squeezes shut the blood flow the tear needs to heal. Treatment has to break that loop with softer stool and a more relaxed muscle at the same time. A fissure present less than about eight weeks is acute and looks like a fresh paper cut. Beyond that it is chronic, and the edges thicken. Most sit in the midline, front or back; one off to the side, several at once, or one that does not hurt is atypical and prompts a look for another cause such as Crohn's disease, an infection or, rarely, a cancer.
Symptoms
The pattern is distinctive enough that patients usually describe it the same way.
- Sharp, tearing or knife-like pain at the moment the stool passes
- Burning or aching afterward, lasting minutes to a few hours
- A small amount of bright red blood on the paper or on the surface of the stool
- A tight, gripping spasm in the anal muscle
- Itching, or a small tag of skin near the tear
- Dreading the next bowel movement, and holding stool because of it See a doctor promptly if painful bowel movements have gone on for more than two weeks, keep coming back after a stretch of healing, or arrive with bleeding you cannot account for. Any new rectal bleeding doctor Fort Smith visit is worth scheduling at 45 or older rather than assuming the cause. Go to the emergency department for a swollen, hot, worsening lump near the anus with fever or chills, which suggests an abscess rather than a fissure, or for heavy bleeding or bleeding with dizziness.
Anal fissure or hemorrhoids?
This distinction changes the treatment, and it comes down to pain. Internal hemorrhoids form high in the canal, in lining that carries almost no pain sensation, so the usual story is blood you can see and nothing you can feel. A fissure sits lower down, in nerve-rich skin, so it hurts sharply and predictably every time you go. Plenty of people have both at once, which is how treating the hemorrhoid alone can leave the pain exactly where it was. Our hemorrhoid symptoms page covers that side; an exam settles it in a few minutes.
How an anal fissure is diagnosed
Usually by looking. Dr. Herraka takes a history of the pain and your bowel pattern, then gently inspects the area; in most cases the tear is visible without any instrument. If the area is too painful, a digital exam or anoscopy is deferred until treatment has calmed things down. Testing beyond the exam is not routine. A colonoscopy is recommended when the bleeding does not fit the story, your bowel habits have changed, or you are 45 or older and due for screening.
Treatment
Nearly all fissures are treated conservatively first, and most acute ones heal that way. Soften the stool and keep it soft. Fiber and fluid, with a supplement such as psyllium if diet alone falls short, plus a stool softener while the tear heals. Stopping this too early is the most common reason fissures come back. Warm sitz baths. Sitting in a few inches of warm water for ten to fifteen minutes after a bowel movement, and once or twice more during the day, eases the spasm and the burning. Prescription ointments. Topical nitroglycerin and topical calcium channel blockers such as diltiazem relax the sphincter and let blood return to the tear so it can heal. Headache is a common side effect of the nitroglycerin form. Which one is appropriate is decided after an exam. When a chronic fissure does not heal. Two options remain, both carried out by a colorectal surgeon: Botox injected into the sphincter, which relaxes it for a period of weeks and gives the tear a window to close, or lateral internal sphincterotomy, an operation with the highest healing rate of any fissure treatment but a small risk of lasting change in bowel control. Dr. Herraka talks both through with you, makes the referral to a colorectal surgeon at OU or UAMS, and stays involved in your care afterward. Preventing the next one. Hard stool and straining are behind most fissures, so treating chronic constipation treatment is part of treating the fissure and keeping it from coming back.
What to expect at your visit
Tell the scheduler that bowel movements are painful, and bring your medication list and anything you have already tried. Expect a conversation first, then a gentle exam at the pace your comfort allows. You leave with a written plan and a follow-up to check healing. For most plans, no referral is needed.
Cost & insurance
An office visit and exam for a fissure are covered by most plans when medically necessary. Compounded ointments vary by plan, and our staff can check yours before you fill it. We take most major insurance, Medicare, and Medicaid in both Arkansas and Oklahoma; details are on our insurance page.
Frequently asked questions
Is it an anal fissure or a hemorrhoid?
Pain is the clue. An anal fissure causes sharp, tearing pain during the bowel movement that lingers afterward, usually with a streak of bright red blood. Internal hemorrhoids most often bleed without pain at all. Many people have both conditions at the same time, so an exam settles it far more reliably than matching symptoms at home.
How long does an anal fissure take to heal?
Many acute fissures settle within a few weeks once stools are soft and the spasm eases; chronic fissures take longer and often need more than fiber and sitz baths. No exact timeline can be promised, since it depends on how long the tear has been there. If pain has gone on more than two weeks, have it looked at rather than waiting it out.
Does an anal fissure need surgery?
Usually not. Fiber, stool softeners, sitz baths and a prescription ointment heal most anal fissures. Surgery is considered only for chronic fissures that have not responded, and is performed by a colorectal surgeon after an evaluation.
Do anal fissures come back?
They can, usually because the stool got hard again. Keeping stools soft for months after the pain is gone is what prevents a repeat.
Can an anal fissure be a sign of something more serious?
Most are exactly what they look like: a tear from a hard stool. One that sits off the midline, appears with diarrhea or weight loss, keeps returning, or refuses to heal raises the question of Crohn's disease, an infection or, less often, a cancer, and that is when a broader work-up makes sense.
Get anal fissure treatment in Fort Smith
Pain with every bowel movement is not something to live with. Call the Digestive & Liver Center of Arkansas Main Clinic at (479) 242-2888 or request an appointment to see Dr. Ihab Herraka at 3416 Old Greenwood Rd, Fort Smith, AR 72903, Monday through Friday, 8:00 to 5:00. We see patients from across the River Valley and from Poteau, Sallisaw and eastern Oklahoma, where Oklahoma Medicaid is accepted.