Intended for healthcare professionals

Practice 10-Minute Consultation

Chronic anal fissure in adults

BMJ 2022; 376 doi: (Published 12 January 2022) Cite this as: BMJ 2022;376:e066834
  1. Artaza Gilani, general practitioner in north west London; honorary lecturer1,
  2. Gillian Tierney, consultant general and colorectal surgeon; honorary professor2
  1. 1UCL Research Department of Primary Care and Population Health, University College London Medical School (Royal Free Hospital Campus), London NW3 2PF, UK
  2. 2Royal Derby Hospital, Derby DE22 3NE, UK; University of Nottingham, Nottingham NG7 2RD, UK
  1. Correspondence to: Artaza Gilani artaza.gilani{at}
  • Accepted 26 November 2021

What you need to know

  • Anal fissure generally causes extreme pain that may be debilitating—severe, sharp pain during defecation and significant post-defecation pain

  • Less common causes (such as inflammatory bowel disease and malignancy) need to be considered, especially if the fissure is irregular, recurrent, multiple, persistent or non-healing, or located laterally

  • Most primary fissures heal with lifestyle and pharmacological (topical glyceryl trinitrate or diltiazem) measures. Botulinum toxin and surgical options may be explored in secondary care

An otherwise healthy 24 year old schoolteacher presents with a three month history of sharp, severe anal pain on defecation. There is bright red blood on wiping and an intense burning pain that persists for several hours after bowel movements. He is on sick leave because the pain is so extreme.

An anal fissure is a tear in the skin of the anal canal.1 Anal fissures are common, particularly in middle aged adults, children, and infants.2 There is no consensus on the timeframe that makes a fissure chronic, but most sources consider the cut-off to range from four to 12 weeks.3 Presentation to primary care is commonly delayed due to embarrassment, despite the often highly distressing symptoms. Topical treatments can be effective, although side effects are common. This article outlines a primary care consultation with an adult presenting with symptoms of a chronic anal fissure.

How this article was created

We searched Medline and the Cochrane Library using the terms “anal fissure” “anal fissure diagnosis” “anal fissure treatment” and “anal fissure management.” Formal guidelines from the National Institute for Health and Care Excellence (NICE) on anal fissure have not been published, but there is a Clinical Knowledge Summary (CKS) topic on anal fissure, which we used for reference. We also made use of UpToDate and BMJ Best Practice.

What you should cover


Symptoms of painful defecation and rectal bleeding are strongly suggestive of an anal …

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