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JAMA Patient Page
March 19, 2014

Anal Fissure

JAMA. 2014;311(11):1171. doi:10.1001/jama.2014.214

An anal fissure is a tear in the opening of the anus that can cause pain, itching, and bleeding.

Anal fissures are common in infants but less so in older children. They occur in adults of all ages. The pain, which can be quite severe, usually occurs during and after a bowel movement. The most common cause of anal fissures is constipation, but diarrhea can be a cause as well. Anal fissures often result from a cycle in which you have pain as a result of constipation, avoid having a bowel movement, and thus worsen the constipation. Treatment involves changing your diet to eliminate diarrhea or constipation, or topical medications to help heal the tear. However, some people need surgery to treat an anal fissure. Anal fissures are not associated with cancer, but you should always talk to your doctor if you have bleeding with a bowel movement.

Symptoms and Diagnosis

The most common symptoms are pain when having a bowel movement and blood on the toilet tissue. Acute anal fissures usually get better quickly. A chronic fissure, which can be more difficult to treat, is one that has lasted more than 6 weeks.

A doctor can usually easily see if you have an anal fissure. To make the diagnosis, he or she might use an instrument called an anoscope to examine the anal canal.


Constipation can cause the skin of the anus to tear. When that happens, the pain of a bowel movement can cause spasms in the anal sphincter muscle. This in turn means that less blood flows to the area, making it more difficult for the fissure to heal. The pain can also cause people to resist having a bowel movement, which worsens the constipation. Other causes include diarrhea and Crohn disease.

If you have anal pain for more than 10 days, you should see a doctor to rule out an infection, a complication of inflammatory bowel disease, a hemorrhoidal condition, or anal cancer.


Home and over-the-counter treatments include sitting in a warm bath; treating constipation with a high-fiber diet, a fiber supplement, and plenty of liquids; and nonprescription ointments including petroleum jelly, 5% lidocaine or 2.5% lidocaine plus 2.5% prilocaine, zinc oxide, or 1% hydrocortisone cream.

A second line of treatment may be prescription-strength topical ointments containing medications such as nitroglycerin, diltiazem, or nifedipine to relax the sphincter muscles.

Another treatment option is surgery, usually done in an outpatient setting. One type of surgery involves injecting botulinum toxin into the anal sphincter. Another kind of surgery involves an operation to cut a small portion of the internal anal sphincter. This improves blood flow to the tear and reduces spasm. Surgery does not heal the tear but is usually successful in preventing anal fissures from recurring.

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For More Information

To find this and previous JAMA Patient Pages, go to the Patient Page link on JAMA’s website at jama.com. Many are available in English and Spanish. A Patient Page on constipation was published in the October 2, 2013, issue.

The JAMA Patient Page is a public service of JAMA. The information and recommendations appearing on this page are appropriate in most instances, but they are not a substitute for medical diagnosis. For specific information concerning your personal medical condition, JAMA suggests that you consult your physician. This page may be photocopied noncommercially by physicians and other health care professionals to share with patients. To purchase bulk reprints, call 312/464-0776.
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Article Information

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Source: McQuaid KR. Gastrointestinal disorders. In: Papadakis MA, McPhee SJ, Rabow MW, Berger TG, eds. Current Medical Diagnosis and Treatment 2014. New York, NY: McGraw-Hill; 2013:chap 15.

Topic: Digestive System