Anal Fissures and Anorectal Conditions in Northern Virginia

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Anal fissure treatment in Northern Virginia begins with a correct diagnosis, and that is where many people run into trouble. Pain with bowel movements, a streak of bright red blood on the toilet paper, and persistent itching around the anus are among the most common reasons adults see a gastroenterologist, and they are also among the most frequently self-diagnosed. Nearly everyone assumes the problem is hemorrhoids. Often it is not. An anal fissure, a small tear in the lining of the anal canal, causes a sharp pain that hemorrhoids rarely do, and it responds to different treatment. Itching has its own list of causes. And a painful, swollen area near the anus, especially with fever, can be an abscess that needs prompt drainage rather than a cream. This guide covers the benign anorectal conditions that are not hemorrhoids: what they are, how they are treated, and when rectal symptoms need an examination rather than another trip to the pharmacy aisle.

These are private symptoms, and many people put off care for months because of embarrassment. Our physicians see these conditions every week. The examination is brief, and the relief that follows an accurate diagnosis is usually considerable. This article is general education, not medical advice.

What an anal fissure is

An anal fissure is a small split or tear in the thin, moist tissue that lines the lower rectum and anus, according to the National Library of Medicine's MedlinePlus encyclopedia. The tear sits in the anoderm, the sensitive skin of the anal canal just inside the opening, which is why a fissure hurts far more than its size would suggest. The American College of Gastroenterology, in its 2021 clinical guideline on benign anorectal disorders, describes the clinical hallmark as pain during a bowel movement that often persists afterward, with bleeding that is usually limited to a small amount of bright red blood on the toilet tissue.

Fissures are common. The StatPearls reference maintained at the National Library of Medicine estimates that 240,000 to 342,000 new cases are diagnosed in the United States each year, and puts the lifetime risk at roughly 7.8 percent. They affect men and women equally and can occur at any age. MedlinePlus notes that fissures are especially common in infants, in women after childbirth, and in people with Crohn's disease.

How an anal fissure differs from hemorrhoids

The two conditions are confused constantly, in both directions. The differences matter because they are treated differently.

• Pain. A fissure typically causes sharp pain during a bowel movement, often described as a tearing sensation, that can linger for minutes to hours afterward. Internal hemorrhoids usually do not hurt. External hemorrhoids can ache or throb, particularly when a clot forms in one, but the pain is not tied to the act of passing stool in the same way.
• Bleeding. Both can cause bright red blood on the paper. Fissure bleeding is usually small in amount and accompanied by pain. Hemorrhoid bleeding often occurs without pain.
• The lump. A chronic fissure often develops a small skin tag at its outer edge, called a sentinel tag. The ACG guideline notes that patients frequently describe this tag as a painful hemorrhoid. It is not one, and treating it as one does not help the fissure underneath.

A physician can usually tell the two apart in a brief examination, and can often see a fissure simply by gently spreading the skin at the anal opening. Our guide to hemorrhoid treatment in Northern Virginia covers the hemorrhoid side of this comparison in detail, and our page on hemorrhoid banding explains why banding is a treatment for internal hemorrhoids specifically and not for fissures or skin tags.

Why anal fissures happen and why some do not heal

In adults, MedlinePlus lists passing large, hard stools and having diarrhea for a long time as the usual causes, with reduced blood flow to the area and excess tension in the sphincter muscles as contributing factors. Those last two explain why some fissures linger. The ACG guideline describes a cycle in which the internal anal sphincter, the ring of muscle that controls the anus, goes into spasm in response to the tear. The spasm reduces blood flow to the already poorly supplied tissue, and the tear cannot heal. Pain leads to fear of the next bowel movement, which leads to withholding, which produces a harder stool and a fresh injury.

Location is a clue to cause. According to the ACG, almost 90 percent of ordinary fissures sit in the posterior midline, toward the tailbone, with most of the rest in the anterior midline. A fissure that is off to one side, or more than one fissure at once, is a different matter. The ACG lists Crohn's disease, tuberculosis, syphilis, HIV, skin conditions such as psoriasis, and anal cancer among the conditions that lateral fissures should raise suspicion for. The American Academy of Family Physicians states plainly that multiple fissures or fissures located lateral to the midline should raise suspicion for Crohn's disease, and that colonoscopy is warranted. This is one of the clearest reasons an examination matters: the location of the tear changes what needs to happen next.

Acute versus chronic anal fissures

Timing changes the treatment. The American Society of Colon and Rectal Surgeons, in its 2023 clinical practice guideline, defines an acute fissure as one present for less than six weeks. The ACG guideline uses a longer window, defining a chronic fissure as one lasting more than 8 to 12 weeks. A chronic fissure looks different under examination: the edges thicken, a sentinel tag forms at the outer margin, and a small enlarged fold of tissue called a hypertrophied papilla may develop inside the canal. StatPearls estimates that about 40 percent of acute fissures go on to become chronic, which is the strongest argument for treating an acute fissure properly the first time rather than waiting it out.

Anal fissure treatment in Northern Virginia: the first step

Most acute fissures heal without any prescription. The ACG guideline reports that almost half of all patients with an acute anal fissure heal with sitz baths and fiber supplements such as psyllium as the first step in therapy, with pain and bleeding relief and virtually no side effects. The ASCRS guideline reaches the same conclusion and states that nonoperative treatment of acute fissures is safe and should typically be first-line treatment.

In practice, the first step has three parts:

• Softer stool, every day. The goal is a soft stool that passes without straining. MedlinePlus recommends more fiber from fruits, vegetables, and grains, more fluids, and a stool softener if needed. A fiber supplement is often the simplest way to get there. If constipation is a recurring problem, our guide to chronic constipation covers it in more depth.
• Sitz baths. MedlinePlus describes sitting in warm water that covers only the hips and buttocks, two to three times a day for 10 to 15 minutes each time. Warm water relaxes the sphincter and eases the spasm that keeps the fissure from healing.
• Soothing the skin. MedlinePlus lists petroleum jelly, zinc oxide, 1 percent hydrocortisone cream, and similar over-the-counter products, along with a numbing cream if pain is interfering with bowel movements. Ask a physician or pharmacist which is appropriate before using a numbing product.

Two things not to do: MedlinePlus cautions that avoiding bowel movements because of pain only makes the stool harder and the fissure worse. And the AAFP notes that manual anal stretching, an older approach, is not an effective treatment.

Prescription options when a fissure becomes chronic

When a fissure has not healed with the measures above, or has already become chronic, treatment shifts to relaxing the internal sphincter so blood flow returns and the tear can close. All of the options below do that in different ways, and the choice among them is a conversation with your physician.

• Topical calcium channel blockers. The ACG guideline recommends a topical calcium channel blocker, such as nifedipine or diltiazem ointment, as the initial medical treatment of a chronic fissure. The ASCRS guideline agrees that these have similar effectiveness to topical nitrates with a better side-effect profile.
• Topical nitroglycerin. An older option that works the same way. The ASCRS guideline reports healing in approximately half of patients with chronic fissures, but headache affects at least 30 percent of people who use it and leads up to 1 in 5 to stop treatment. That is why calcium channel blockers have moved to the front of the line.
• Botulinum toxin injection. The ACG suggests botulinum toxin injected into the sphincter for people in whom a calcium channel blocker has not worked, or as an alternative to one. The ASCRS reports healing similar to topical therapy as a first-line option, with modest additional benefit as a second-line one, and notes that it can cause temporary loss of stool control in about 5 percent of cases. The effect on the muscle wears off over a few months.

These ointments are prescription products, compounded for this purpose, and are not the same as the hemorrhoid creams on a drugstore shelf.

Surgery for anal fissures that do not heal

For a chronic fissure that has not responded to nonsurgical measures, the ACG guideline recommends a procedure called lateral internal sphincterotomy as the surgical treatment of choice, with a strong recommendation backed by high-quality evidence. The ASCRS guideline describes it as the treatment of choice for chronic fissures in selected patients who do not already have trouble with stool control. The surgeon divides a small portion of the internal sphincter to relieve the spasm permanently. The ASCRS reports healing rates of at least 88 percent for up to six years.

The trade-off is the reason it is reserved for fissures that have failed other treatment. Because the procedure weakens the sphincter slightly, some patients experience a change in stool control afterward. The ASCRS notes that some degree of incontinence can affect up to 30 percent of patients after surgery, though for most it is minor, such as difficulty controlling gas, and improves over time. StatPearls reports that the rate falls to under 10 percent by five years, with loss of solid stool in under 1 percent. Surgeons weigh this risk carefully in women who have had vaginal deliveries, older adults, and anyone whose control is already imperfect. Sphincterotomy is performed by a colorectal surgeon, and a gastroenterologist's role is to confirm the diagnosis, exhaust the medical options, rule out an underlying condition such as Crohn's disease, and make the referral when it is appropriate.

Anal itching, or pruritus ani

Persistent itching around the anus is, according to the American Academy of Family Physicians' 2020 review of benign anorectal conditions, the second most common anorectal symptom. It has many possible causes, and in a large share of cases no single cause is ever identified. Among the causes that can be identified, the AAFP lists:

• Anorectal conditions, including hemorrhoids and anal fissures, which allow small amounts of moisture or stool to reach the skin
• Skin conditions such as contact dermatitis, irritant dermatitis, and lichen planus
• Infections, including pinworms, which are common in school-aged children and can spread within a household
• Foods and drinks, with beer, citrus fruit, coffee, dairy, spicy foods, and tomatoes as examples
• Nerve irritation from the lower back in people with chronic back pain

The most common trap is over-treating. The skin around the anus is delicate, and soaps, fragranced products, medicated wipes, and vigorous cleaning after every bowel movement irritate it further. Scratching, including in sleep, does the same. The AAFP recommends rinsing the area with water before drying, avoiding fragrances, cleansers, and hygienic wipes, applying a barrier such as petroleum jelly, and wearing loose cotton clothing to keep the area dry. A short course of low-strength hydrocortisone cream is sometimes used, limited to one to two weeks because longer use thins the skin. When the diagnosis is unclear or initial treatment does not work, a culture or a small skin biopsy may be needed, because a few uncommon skin cancers can present as persistent itching. Itching that continues despite several weeks of gentle care deserves an examination rather than a stronger cream.

Anal abscess and fistula: when swelling and pain need prompt care

An anorectal abscess is a pocket of infection in the tissue around the anus and rectum. StatPearls describes the typical presentation as a sudden onset of severe pain and swelling, and notes that the throbbing pain is not tied to bowel movements the way fissure pain is. Fever may accompany it. This is not a condition that responds to creams, sitz baths, or antibiotics alone. An abscess needs to be drained, and StatPearls notes that untreated infections can spread. Fever, spreading redness, deep pelvic pain, or difficulty urinating alongside anal pain are reasons to seek care the same day, through an emergency department if an office visit is not available.

After drainage, a tunnel called a fistula sometimes remains, connecting the inside of the anal canal to the skin. StatPearls reports that among people whose abscess did not already involve a fistula, roughly 30 to 50 percent develop one in the following months to years. A fistula typically causes recurring drainage, irritation, and repeat infections, and it generally requires a surgical procedure to close. Fistulas are also strongly associated with Crohn's disease, which is why a gastroenterologist evaluating an abscess or fistula, particularly a recurrent or complicated one, will consider whether inflammatory bowel disease is the underlying problem.

When rectal symptoms need a scope, not a cream

Most benign anorectal conditions are diagnosed by history and a brief examination, sometimes with anoscopy, a short lighted tube that lets the physician see the inside of the anal canal. Certain findings call for a look further in. An examination or endoscopy is warranted rather than continued self-treatment when:

• Bleeding continues for more than a week or two despite fiber and sitz baths, or is more than a small streak on the paper. Rectal bleeding has several causes beyond hemorrhoids and fissures, and our guide to blood in stool explains why it should never simply be assumed to be hemorrhoids.
• A fissure sits off the midline, or there is more than one, which the AAFP states should prompt colonoscopy to evaluate for Crohn's disease.
• A fissure has not healed after six to eight weeks of consistent home care.
• Itching persists for weeks despite gentle hygiene measures, or the skin looks thickened, ulcerated, or otherwise abnormal.
• Symptoms are accompanied by a change in bowel habits, unexplained weight loss, or a family history of colorectal cancer.
• You are 45 or older and are not current on colorectal cancer screening. The AAFP notes that screening should be considered for symptomatic patients who are due, and can also be considered for symptomatic patients in their 40s because of rising cancer rates in that age group.

Rectal symptoms in a person who is due for screening are often the moment that screening finally happens, and that is a reasonable outcome. Our guide to when to see a gastroenterologist walks through the broader decision.

Anal fissure treatment in Northern Virginia with GC of NoVA

Gastroenterology Center of Northern Virginia evaluates and treats anal fissures, anal itching, and other benign anorectal conditions for patients across Arlington, Annandale, and the surrounding communities. Our physicians can confirm whether the problem is a fissure, a hemorrhoid, a skin condition, or something that needs a closer look, prescribe the compounded ointments that heal chronic fissures, and arrange colonoscopy or a surgical referral when either is warranted. We see patients at our Arlington office, next to VHC Health, and our Annandale office, in the Woodburn Medical complex. If this would be your first visit with a gastroenterologist, our guide to what to expect at a first appointment explains how the visit goes. Patient information on anal fissures is also available from MedlinePlus.

To schedule an evaluation, contact our Arlington office at (703) 522-7476 or our Annandale office at (703) 560-6106, or learn more at gcofnova.com.

This article is for general education and is not medical advice. Talk with a qualified gastroenterologist about your symptoms, diagnosis, and treatment options.