An anal fissure is a small tear in the lining of your anal canal — the short passage at the end of your bowel. Most fissures form at the back of the canal (the posterior midline). They are extremely common — they affect people of all ages, including during and after pregnancy — and they are one of the most frequent causes of severe pain around the bottom and fresh blood on the toilet paper. Please know that this is a very common and well recognised condition, you are not alone, and there is good treatment available.
An acute fissure is a fresh, recent tear. Most of these heal on their own within 4–6 weeks with simple measures. A chronic fissure is one that has been there for longer than 6–8 weeks and has not healed. With a chronic fissure, you may notice a small skin tag nearby or feel a firmer edge to it — this happens because the muscles around the fissure go into a kind of protective spasm that, over time, actually reduces blood flow to the area and makes healing harder. That is why some fissures need help beyond diet and creams.
The most common symptom is sharp or burning pain during and after a bowel movement — it can last anywhere from 30 minutes to a few hours after going to the toilet. You may also notice bright red blood on the toilet paper or in the pan, and sometimes itching or irritation around the area. It is very natural to start avoiding going to the toilet because of the pain, but try not to put it off — waiting leads to harder stools, which makes the fissure worse. Keeping stools soft is one of the most important things you can do right now.
An anal fissure is usually diagnosed from your description of symptoms alone — the combination of severe pain and fresh bleeding with bowel movements is quite characteristic. A gentle examination can confirm it directly, though this is deferred if it is too uncomfortable at the time. Mr Nguyen will assess whether the fissure is acute or chronic, check for a skin tag or muscle spasm, and note its position. Fissures in an unusual location may warrant further investigation to exclude an underlying condition such as Crohn's disease.
Treatment always starts simply. The first step is making stools softer and easier to pass — this means eating plenty of fibre (aim for 25–30 g a day), drinking plenty of water, and taking a stool softener if needed. On top of that, a medicated cream is applied around the area to help relax the surrounding muscle and improve blood flow to help the tear heal. Mr Nguyen's preferred cream is nifedipine ointment, applied 2–3 times a day. Because this is not available off the shelf in Australia, it needs to be made up for you by a compounding chemist — Mr Nguyen will guide you on this. Glyceryl trinitrate (GTN) ointment is a widely available alternative if needed. Most fresh fissures respond well to these steps. If your fissure has been there a while and has not healed with creams, the next option is a botulinum toxin (Botox) injection into the muscle — this gently relaxes the spasm, helps blood flow return, and allows healing. This works in around 70% of cases. If the fissure still does not heal, a small procedure called a lateral internal sphincterotomy — where a tiny portion of the muscle is divided — is the most effective treatment, with healing rates above 90%.
Mr Nguyen's approach is careful and stepwise — he always tries the gentler options fully before moving to anything more involved. Creams are trialled first; if those do not work, a Botox injection is the next step; and only if that is not enough is a small surgical procedure considered. Protecting the sphincter muscle (the ring of muscle that controls bowel control) is central to every decision. Both the injection and the sphincterotomy are done as day procedures under sedation or a short general anaesthetic — you go home the same day.
If your pain has been going on for more than 4–6 weeks despite trying creams and dietary changes, it is worth seeing a specialist. Also worth noting: most fissures occur at the back of the anal canal. If yours seems to be in a different position, or if you have other bowel symptoms, please get it checked — occasionally an unusual position can point to an underlying condition such as Crohn's disease that needs its own attention.
Your GP will refer you to Mr Nguyen, and in most cases you will be seen within one to two weeks. At the consultation, Mr Nguyen will take a detailed history, examine the area gently, and discuss a stepwise treatment plan with you. For most patients this starts with dietary advice and a prescription cream — no procedure needed straight away. If a procedure is later recommended, it is done as a day case and you go home the same day. Follow-up is arranged to check healing.
Aim for 25–30 g of fibre a day, drink around 2–3 litres of water, and if stools are still hard, a stool softener like lactulose or Movicol is completely fine to take. Most importantly, go to the toilet when you feel the urge — do not hold on, as this makes stools harder and the pain worse.
There is a small risk of minor changes to bowel control — most commonly a slight looseness with wind — with a sphincterotomy. Mr Nguyen discusses this with you before any decision is made. For the right patient, the benefit of finally healing a painful fissure clearly outweighs this small risk, and most people have no problems at all.
No — the injection is done under sedation or a short general anaesthetic, so you will not feel it during the procedure. Some mild discomfort in the area for a day or two afterwards is normal, but most people manage this comfortably at home.
It can, particularly if constipation is an ongoing problem. The Botox injection has a higher chance of the fissure returning than the surgical option, but it can be repeated if needed. Long-term attention to diet and staying hydrated is the best way to prevent recurrence.
If you have questions or would like to be seen, Mr Ba Nguyen consults at his rooms in Heidelberg and operates at Warringal Private Hospital and Epworth Eastern, Box Hill. A GP or specialist referral is needed to make an appointment.