Anal fissure vs haemorrhoids — how to tell the difference

If you're reading this, you probably noticed something worrying after going to the toilet — blood, pain, or both — and you've landed on these two conditions as possible explanations. They are easy to confuse, and that confusion matters because the treatment for one doesn't work for the other. An anal fissure is a small tear in the lining of your anal canal, and its defining feature is pain. An internal haemorrhoid is an enlarged blood vessel cushion, and its defining feature is bleeding or prolapse — usually without much pain at all.

The single most useful clue before you see anyone is pain. If going to the toilet is painful, and the pain lingers for a long time afterwards — sometimes an hour or more — an anal fissure is most likely what you're dealing with. If you're seeing blood but there's little or no pain, internal haemorrhoids are the more likely culprit.

Anal fissure

An anal fissure is a small tear in the lining of the anal canal — almost always at the back midline (what surgeons call the 6 o'clock position). The area is packed with pain-sensing nerves, so even a tiny tear hurts a lot. Every time you pass a bowel motion, the tear gets disturbed again, and the muscle around the anus goes into spasm in response. That spasm actually reduces blood flow to the area, which is why fissures can stubbornly refuse to heal on their own for months or even years if they're not properly treated.

Haemorrhoids

Haemorrhoids are enlarged blood vessel cushions inside and around the anal canal. The internal ones — the most common type — sit high enough up that there are no pain-sensing nerves there, which is why they tend to bleed without hurting. Their main symptoms are bleeding, a lump that comes out after a bowel motion (prolapse), mucous discharge, and itching. External haemorrhoids are lower down, covered by skin that does have pain nerves, so they can be sore — especially if a blood clot forms inside one (called a thrombosis). The key takeaway: if you have internal haemorrhoids, pain is not usually part of the picture.

Why fissures occur

Fissures are usually caused by the anal canal being stretched too much — most often by a hard or large stool passing through. Bouts of diarrhoea can also cause them, as can childbirth. The back midline of the anal canal (where fissures almost always happen) has slightly less blood supply than other areas, which is part of why it heals poorly once injured.

Why haemorrhoids occur

Haemorrhoids develop when the connective tissue and ligaments that hold the blood vessel cushions in place gradually weaken. Chronic straining, pregnancy, and a low-fibre diet that produces hard stools are the main triggers. Unlike a fissure, a haemorrhoid isn't a wound — it's more of a structural change in normal tissue. That's why haemorrhoids are treated with procedures that cut off their blood supply or remove the tissue (rubber band ligation, surgery), while fissures are treated with things that relax the muscle and improve healing.

• You have noticeable bleeding combined with severe pain — you may have both a fissure and haemorrhoids at the same time, or something else that needs checking
• Your symptoms haven't improved after 4–6 weeks of conservative management
• You have swelling, redness, or a fever around that area — this can be a sign of an abscess that needs prompt attention
• Your fissure is not at the back midline — fissures in unusual positions can indicate Crohn's disease or another underlying condition
• You're over 40 and have rectal bleeding without a recent colonoscopy — it's worth ruling out other causes

This is why the diagnosis matters. If you have a fissure and you're using haemorrhoid cream, you might get a little surface relief, but you're not touching the real problem — the muscle spasm that's stopping the tear from healing. And if you're treating a haemorrhoid with fissure cream designed to relax a sphincter, you're not addressing the blood vessel enlargement at all. The treatments don't cross over.

Treating anal fissures

The first step is always softening your stools and taking warm sitz baths (sitting in a few centimetres of warm water for 10–15 minutes) — simple things that work well for fresh fissures. If your fissure has been around for more than 6–8 weeks, your doctor will likely prescribe a topical ointment (such as nifedipine, diltiazem, or glyceryl trinitrate) that relaxes the muscle and improves healing, used twice daily for about 8–10 weeks. If that does not work, botulinum toxin (Botox) injected into the sphincter during a short day procedure heals most remaining fissures. The final step — lateral internal sphincterotomy — is a small surgical procedure for the cases that have not responded to anything else, and in published series has a high cure rate.

Treating haemorrhoids

Haemorrhoid treatment moves from dietary and lifestyle changes → rubber band ligation (banding) → day-surgery options like HALRAR or Rafaelo → surgical haemorrhoidectomy, depending on how severe your haemorrhoids are. Banding is a simple clinic procedure — no anaesthetic needed — and is suitable for most grades of internal haemorrhoids. Surgery is reserved for the more severe or persistent cases.

The bottom line: the treatments for these two conditions are different because the conditions themselves are different. Getting the right diagnosis makes all the difference.

Yes — and it happens more often than you might expect. If you've had haemorrhoids for a while and then pass a hard stool, you can develop a fissure on top of the existing haemorrhoids. The haemorrhoids cause the bleeding; the fissure causes the pain. When both are present, the fissure is usually treated first — it needs to heal before a proper examination can be done and before the haemorrhoids can be addressed. Your surgeon will work through this in the right order for your situation.

For fissures: surgery (lateral internal sphincterotomy) is the next step when topical creams and botulinum toxin injections have not produced healing. It is a day procedure, and in published series most people are healed within a few weeks.

For haemorrhoids: surgery (haemorrhoidectomy) is used for Grade IV haemorrhoids, Grade III ones that haven't responded to banding, and larger external haemorrhoids. Both operations are planned procedures — nothing urgent — and can be scheduled around your life.