Haemorrhoids vs anal fissure — how to tell the difference

Haemorrhoids are enlarged, swollen blood vessel cushions in and around the anal canal. They develop when the tissue that normally lines the lower rectum and anal canal becomes engorged and starts causing symptoms. They are common — most adults will experience them at some point.

An anal fissure is a small tear in the skin and tissue lining the anal canal — like a paper cut, but in one of the most sensitive spots in the body. It's usually caused by a hard or large stool that stretches the anal opening further than it can comfortably handle. The tear almost always forms at the back midline of the anal canal.

Both conditions can cause rectal bleeding and anal discomfort — which is why they get confused. But the character of the pain, the pattern of bleeding, and the way each condition plays out over time are different enough that you can usually tell them apart — and a clinician certainly can.

The single most useful clue is the character and timing of the pain.

Haemorrhoids — the pain picture

Internal haemorrhoids, which sit above the dentate line, have no pain nerve supply at all — so they can bleed quite a lot without causing any pain. Grade I to III internal haemorrhoids often bleed noticeably but cause no discomfort whatsoever. External haemorrhoids, and internal haemorrhoids that have prolapsed, can cause a dull ache, a feeling of pressure or fullness, and some discomfort when sitting. The exception is a thrombosed external haemorrhoid — where a blood clot forms inside the haemorrhoid — which causes severe pain that typically peaks in the first 24–48 hours and a firm, tender lump.

Anal fissure — the pain picture

Fissure pain is distinctive — and once you know what to look for, it's readily recognisable. It's typically sharp, burning, tearing, or knife-like. It starts when you go to the toilet and then continues long after — anywhere from 30 minutes to several hours. That lingering pain happens because the anal sphincter muscle goes into reflex spasm after the tear, and stays contracted. The spasm hurts, and it also cuts off blood supply to the area, which is why fissures can be so stubborn about healing.

People with fissures often start dreading going to the toilet, which makes them put it off, which leads to constipation, which makes the stool harder, which makes the fissure worse — a cycle that explains exactly why fissures become chronic.

Both conditions cause bright red rectal bleeding. But there are differences in how much and what it looks like:

• Haemorrhoidal bleeding is often more voluminous — it can drip or spray into the toilet bowl, sometimes in amounts that look alarming even when you're otherwise completely well.
• Fissure bleeding is typically lighter — a smear or streak of bright red blood on the toilet paper, or a small amount in the bowl. It's always fresh (bright red), never dark or mixed through the stool.
• Both conditions produce blood on the toilet paper. Neither should cause dark blood or blood mixed through the bowel motion — if you're seeing that, it needs urgent evaluation for a source higher up.

Yes — and it's more common than you'd think. Chronic constipation and straining are risk factors for both, so you can absolutely have bleeding from haemorrhoids and pain from a fissure all at once. Separating the two matters because the treatments are different.

A colorectal surgeon will examine the area and perform a gentle proctoscopy — a short visual inspection of the anal canal with a small, well-lit instrument — to make the diagnosis accurately. If pain is preventing a proper examination in the clinic, it can be done under a brief anaesthetic instead.

Both conditions share the same common risk factors — which is why they often occur together:

• Constipation and straining — hard stools cause haemorrhoids to engorge and fissures to tear; soft stools are your best protection against both
• Low-fibre diet — reduces stool bulk and makes everything harder to pass
• Not drinking enough water — hardens the stool
• Prolonged sitting on the toilet — increases pressure on the anal blood vessels; get in, do your business, get out
• Pregnancy and childbirth — a substantial risk factor for both conditions

The underlying biology is different, though: haemorrhoids are blood vessel cushions that become engorged and enlarged, while a fissure is a physical injury — a tear — made worse by sphincter spasm.

Treating haemorrhoids

Start with the basics — high-fibre diet, good hydration, sitz baths, and avoiding prolonged straining — which can settle many symptomatic haemorrhoids. The most common clinic procedure for internal haemorrhoids is rubber band ligation — a 10-minute procedure without anaesthetic, suitable for Grade I–III disease. Day-surgery options between banding and excisional surgery include HALRAR and Rafaelo. For Grade III–IV or recurrent haemorrhoids, surgical haemorrhoidectomy is the most definitive option.

Treating anal fissures

The goal of fissure treatment is breaking the cycle of spasm. Start with stool softeners, a high-fibre diet, and a topical ointment (such as nifedipine, diltiazem, or glyceryl trinitrate) that relaxes the internal sphincter — applied twice a day for about 8–10 weeks. If the fissure still has not healed, botulinum toxin (Botox) injected into the sphincter during a brief day procedure heals most remaining fissures. Surgery — lateral internal sphincterotomy — is the next step for fissures that have not responded to anything else, and in published series has a high cure rate.

The key takeaway: haemorrhoid cream on a fissure won't work, and fissure cream on a haemorrhoid won't work. The treatments are different because the problems are different.