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If you have an anal fissure, you probably wouldn’t wish it on your worst enemy. My chronic fissure was so bad, I started an entire company to help solve it (oh, and I also had surgery where they cut my anal sphincter muscle). So yeah—I see you, and I’m so sorry. Truly.
About 1 in 10 people will experience an anal fissure (and postpartum women get them even more!). It’s surprisingly common, but no one talks about it. I hadn’t even heard of the term “anal fissure” until I was finally correctly diagnosed—months after I’d been treating my issue as a hemorrhoid.
So What Exactly Is an Anal Fissure?
An anal fissure is a small tear or cut in the delicate lining of the anal canal—the very end of your rectum. Sometimes you can see it with the naked eye, and sometimes it’s only visible during a medical exam. I called mine “the devil’s paper cut.” Cute, right?
Most fissures occur at the back (posterior midline), right where there are tons of sensory nerves—aka, where things hurt a lot. Even a tiny tear can feel like actual torture.
What Causes Anal Fissures?
Poor blood flow to the skin of the anal canal and perianal skin contribute to the development and delayed healing of anal fissures.
The decreased blood flow is usually due to “hypertonic” (overly tight) sphincter muscles that pinch off the tiny blood vessels that go through the muscle fibers up to the skin. When the skin loses its blood supply, it becomes more susceptible to tearing.
Other contributing factors to reduced blood flow (and therefore anal fissures) are:
- Chronic Constipation – straining during bowel movements due to constipation puts pressure on the anal sphincter. That pressure can cause spasms, and those spasms tighten blood vessels and reduce blood flow
- Diarrhea – an intense episode (or chronic episodes) of diarrhea can weaken or cause trauma to the delicate skin.
- Passing Hard or Large Stool – this can cause tears to the skin and/or damage blood vessels, therefore causing muscle spasms which further limit circulation
- Reduced Overall Circulation – Poor cardiovascular health, smoking or diabetes can impair blood flow and delay tissue repair in sensitive areas like the anus.
- Hemorrhoids – in a fun, double whammy (sarcasm) those dealing with inflamed hemorrhoids can also be more prone to anal fissures, due to the increased pressure in the swollen tissues which makes it more prone to tearing
- Age – blood flow naturally decreases with age, and the anorectal area becomes less resilient, making it more prone to injury and slower to heal.
- Childbirth – straining during labor, tissue stretching and trauma during birth and postpartum constipation can all contribute to fissures. As if moms didn’t have enough going on down there!
- Menopause – Anal and vaginal tissues become thinner, drier and more fragile due to decreasing estrogen during menopause. Lower estrogen also can reduce blood flow and contribute to constipation and straining.
- Irritable Bowel Syndrome (IBS) – those with IBS often alternate between diarrhea and constipation and also sometimes have visceral hypersensitivity, meaning their gut and rectum react more strongly to pain and pressure which may amplify spasms in the anal sphincter.
- Crohn’s Disease – a type of inflammatory bowel disease where significant inflammation in the anal area causes one or multiple simultaneous fissures in the same patient.
What Do Anal Fissures Feel and Look Like?
I was never able to visualize my anal fissure (although a doctor was able to) but I WAS able to see a toilet full of bright red blood every time I pooped. Like – a LOT of blood. If you have blood in the toilet, speak to a health care professional right away!
For me, there were two phases of pain every time I had a bowel movement:
A sharp, searing “glass-shard” pain while pooping.
An hour or so later, a deep, burning ache that lasted up to 6–8 hours. That turned out to be muscle spasms—they cut off blood flow and delayed healing. The name of the game? Stop the spasms and increase blood flow.
When an anal fissure becomes chronic (meaning it doesn’t heal on its own and persists over time), the body might develop a “sentinel pile”, a small bump or flap of skin at the edge of the fissure. This is the body’s attempt to protect itself, like a callous on your hand/foot.
This sentinel pile is often mistaken for a hemorrhoid (this was one of my mistakes too!) and that, in addition to the fact many people have never even heard of a fissure, is why many mistakenly diagnose themselves with external hemorrhoids and not an anal fissure.
How Can I Heal Anal Fissures?
Some fissures heal on their own with lifestyle changes. Others need meds. Some become chronic and may require surgery (hi again!).
The goal of any treatment is to relax the anal sphincter muscle. Once the muscle is relaxed, blood flow is restored and the skin can heal.
If you suspect a fissure or have blood in the toilet, see a doctor (ideally a colorectal specialist) and insist on a physical exam. I mistook mine for a hemorrhoid and treated it all wrong for months.
Lifestyle Tips That Actually Help
THINGS TO TRY
- Warm Sitz Baths: Warm water relaxes the sphincter, increases blood flow to the area and encourages healing. Skip the Epsom salt—it’s drying and constricts the skin.
- Fiber + Water: Aim for 25–38g of fiber daily and drink at least 8–10 glasses of water. Keep those poops soft and easy to pass to avoid reaggravating your fissure.
- Pooping Smart: Don’t strain, don’t linger, raise your knees up above your belly button in a squatting position (a toilet stool is useful). Use a bidet or “peri bottle” rather than wiping with paper. If the pain’s super intense, a warm sitz bath or lidocaine spray 30 minutes before going can help by relieving pain and relaxing the area. (We’re making our own spray—stay tuned!)
- Movement & Heat: Gentle exercise improves circulation. Use a warm compress (not ice!)—we want blood flow, not restriction.
- Osmotic Laxatives: Use them if needed, but sparingly. Betty’s physicians recommend MiraLAX (a non stimulant laxative) + eating or supplementing with fiber + lots of water.
THINGS TO AVOID
- Ice pack: While it may feel good temporarily (some nights it was the only way I slept) long term it reduces blood flow. Again, fine for a hemorrhoid, not okay for a fissure!
- Avoid Irritating Foods: Ditch spicy and acidic foods and anything that dehydrates you for now. Coffee is unfortunately on this list. Say it ain’t so!
- Stimulant Laxatives: Avoid stimulant laxatives (anything with senna/sennasoids) which can cause dependence. Docusate sodium (aka stool softener) is typically not helpful.
Over the Counter Options
Honestly? The current options are meh (we’re working on it!).
THINGS TO TRY
- Try a 5% lidocaine cream for numbing + a zinc oxide cream (we like Babo Botanicals) for skin barrier protection. And make sure to join our waitlist (sign up here) to be alerted when our topical solution is on the market later this year.
THINGS TO AVOID
- Phenylephrine: That’s a vasoconstrictor meaning it constricts blood flow—bad for fissures. Not to name names, but it’s present in almost every major hemorrhoid cream, even ones marketed as safe for fissures.
- Witch hazel: This one goes against what you’ve probably heard for years, but witch hazel is not the magic ingredient it’s purported to be. It may feel good short-term because it’s cool and wet, but it can be highly drying and irritating when used regularly. Not what your delicate anal skin needs!
Prescription Options
There are a few options that only your doctor can prescribe that are intended to help restore blood flow to the skin. The main ones are:
- Topical Nitroglycerin: Opens blood vessels but can cause headaches (I can confirm this!).
- Diltiazem/Nifedipine: Fewer side effects of nitroglycerin, but also less effective for large, deep or chronic anal fissures. This one actually gave me a rash which apparently isn’t super common but not unheard of.
I’ve tried both—headaches from one, rash from the other. Still, they can help lots of people so I encourage you to ask your doctor about your options!
When It’s Time for Surgery
There are two common options:
- Botox: Temporarily relaxes the internal anal sphincter muscle. It works but is, well, not fun to receive. And, just like my forehead botox, would potentially need to be readministered every few months if my fissure hadn’t healed. My doc wouldn’t do it unless I was under general anesthesia, so I passed. It’s about 67% successful, so it definitely works for many people!
- Lateral Internal Sphincterotomy: A (typically outpatient) surgery where the surgeon makes a tiny cut in the sphincter muscle to release tension and improve healing. Success rate? Over 98% of fissures heal with this procedure. But there are risks so it’s treated as a last resort only after more conservative methods do not heal the fissure – both for temporary and in some cases, long-term incontinence.
I’ll write a full post on this, but short version: My surgery was a dream. Pain was low (thanks to the pain blockers my doctor gave me when I was under anesthesia), I could poop without pain within a day, and within 2–3 weeks, I felt completely back to myself.
Every body and experience is different. Educate yourself regarding your options and discuss what may be right for your body with your health care professional.
THE BOTTOM LINE
My anal fissure journey was awful. But honestly, the worst part of it was my confusion and embarrassment around my condition and how to address it. At Betty, we’re committed to providing you with the education and support you need from Day 1 to make informed decisions about your health.
If there are ways we can help please reach out via our website or on instagram.
Anastasia