Understanding Anal Fissures: Causes, Symptoms, and Treatment Options

What Is an Anal Fissure?

An anal fissure is a small tear in the external skin of the lining of the anal canal. It usually manifests in the two weakest spots of anyone’s anus: posterior (to the back/tailbone) or anterior (towards the penis/testicular region). The tear exposes the underlying muscle, which, in turn, leads to the manifestation of symptoms (mostly pain). The majority of acute fissures can heal without anal fissure surgery. Instead, an appropriate bowel regimen, as well as the use of topical creams, suppositories, and refraining from anal intercourse, can work effectively.

Unfortunately, many anal fissures that become chronic and non-healing will require surgical intervention. This is because this area of the body is still considered taboo by most, and many refrain from seeking attention and/or the physicians treating them have limited knowledge, specifically of our queer community. A complete understanding of one’s ultimate sexual goals is imperative to the success of any intervention, with the treating physician being well-versed in not only the common ailments that affect our community, but also the appropriate treatments before, during, and, more importantly, post-surgery. Without this knowledge, the outcomes will be subpar.

Anatomy Involved in Anal Fissures

The internal anal sphincter, a smooth muscle layer, maintains resting anal tone and controls involuntary bowel movements. When there’s a tear or break in the delicate lining of the anal canal, the internal sphincter can become overly tense, making it harder for the fissure to heal. This muscle’s involuntary contractions often intensify during episodes of bowel movement, causing pain and even spasms that worsen the fissure. It’s a cycle of muscle tension and insufficient blood flow that impairs the natural healing process.

Causes and Risk Factors

Anal fissures may develop from passing hard stools and/or the trauma associated with anal sex. It’s all about pressures, and one must understand that elevated pressure from both defecation and intercourse can be quite high. With that, the skin and the underlying muscle have only a maximal capacity to withstand that stress. Either the skin is the limiting factor, the underlying muscle, or a combination of both. But regardless, if that pressure goes beyond its limit, it splits.

Anal sex makes an enormous impact on one’s susceptibility to tears, known as anal fissures. These cuts are commonplace for anyone who engages in this type of intercourse. Anal sex tears stem from the localized trauma that can occur from the elevated pressures of anal play. The asshole is truly simple and has two elements of potential injury: the overlying skin and underlying muscle. If one or both are placed under undue stress and are stretched beyond their normal capacity, a fissure will ensue. It doesn’t have to be from forceful, aggressive sex and/or double penetration, though clearly, the more stress and strain, the higher the chances of ripping. It’s multifactorial because it relates to positioning, lubricity, pelvis size, diameter and length of the item inserted, etc. It even happens from defecating!

As stated above, there are two specific locations that are the weakest, the back and the front of the anus opening, and the majority of anal fissures from sex will occur here. It’s purely a pressure issue, especially during anal play. As you can imagine, when you graduate to larger toys and/or fisting, these pressures get exacerbated.

Symptoms and Complications

The most common anal fissure symptoms include:

• Bleeding during or after bowel movements
• Pain, often severe, especially during and after defecation
• Development of a localized skin tag near the fissure
• Sphincter spasms that cause additional pain and difficulty with defecation
• Mucus discharge and/or mild seepage that impact cleanliness
• Persistent burning or localized irritation
• Pain during anal intercourse, which may reduce pleasure or prevent engagement altogether
• Ongoing discomfort or nagging sensation that limits quality of life

Possible Complications

Pain from the fissure can cause muscle spasms in the anal sphincter muscle, which can make it hard for the fissure to heal. Other complications can include:

• Ongoing pain and discomfort
• Trouble having bowel movements
• Not having bowel movements because of pain
• Reduced quality of life
• The fissure coming back after treatment
• Pus-filled infection (abscess)
• Uncontrolled bowel movements and gas

Book your anal fissure surgery consultation at Bespoke Surgical™s New York City location today.

Diagnosis and Treatment Options

Most anal fissures can be diagnosed by a medical professional through visual inspection. While anoscopy is the preferred method since it allows for a thorough evaluation, pain is the limiting factor, and this exam may require the client to be placed under anesthesia or defer the evaluation until it has had sufficient time to heal. The key component is to differentiate between acute and chronic fissures, as this changes the initial treatment pathways. Chronic tearing is actually quite easy to ascertain because an old scar and extra tissue is usually present.

That scarring leads to a bump in the region or a tag called a sentinel pile. This is the normal way in which scarring occurs in the region due to the need to continue to defecate. If this is present, surgical treatment is warranted since the new scarred tissue that is laid down is beyond weak. Take that weakness and add the pressures of defecating and anal play, and you can see the chronic tearing occurring. Lastly, sometimes on visual inspection, there are no issues that are found; however, through discussion, a client will say that once they engage anally, a tear is noted.

With this, we either tell one to have anal engagement the night before we inspect for the best diagnosis, or we schedule an operation under anesthesia to dilate, simulating anal intercourse. This will definitely show the hang-points of friction and, of course, the subsequent tearing. With this new knowledge, it can be treated appropriately. Mostly, this last category is more about history-taking diagnoses, which are missing from far too many other surgical evaluations done by other surgeons. The use of diagnostic anoscopy is essential in our community, specifically as it relates to the way in which we all engage.

Anal Fissure Treatment for Patients with STDs

Anal fissures can become more frequent and severe in individuals battling an STD, as infections like herpes, syphilis, and gonorrhea can compromise tissue integrity and slow healing. In some cases, an STD may exacerbate an existing fissure, leading to persistent pain, inflammation, and an increased risk of secondary infections. While initial management focuses on treating the underlying infection with appropriate drug therapy, persistent fissures that fail to heal may indicate a need for surgical intervention.

Many patients who develop anal fissures while managing an STD have experienced anal discomfort or injury in the past but never sought medical attention. This history of unaddressed trauma can increase vulnerability to both fissures and STDs, creating a cycle of recurring issues. For those in this high-risk category, proactive medical care is crucial—not just for treating fissures but for protecting overall anal health. Timely intervention can prevent further complications, improve healing outcomes, and ultimately support a more comfortable and confident approach to sexual wellness.

How Do I Know If I Have a Hemorrhoid or a Fissure?

It’s sometimes not an easy distinction between a hemorrhoid and a fissure, even for some professionals. Pain with defecation, plus or minus bleeding, may be present with both. Also, some extra skin in the region is another common occurrence. Now, with fissures, many describe the defecating as shitting razors, and you feel a significant anal muscle spasm along with this sensation. This can last for a considerable amount of time after each bowel movement and even debilitate you enough that you have to lie down.

As for external hemorrhoids, it’s pressure, and you can feel a clot from the size of a pea all the way up to a walnut protruding externally. Most hemorrhoids, geographically, are noted on either the left or the right side, whereas a fissure is more posterior towards the tailbone.

You can usually take an anal selfie and send it to us. We get them all the time. From there, we can diagnose and place you on an appropriate treatment plan.

The reality is the treatment for both of these in the acute phase is very similar.

How do you lower the risk of anal sex tears?

The key is to understand your own anatomy prior to anal play in order to mitigate your risk. We speak all the time about using toys to explore safely and to develop an understanding of your own capacity to accept things anally. With gradual dilation, both the skin and the muscle can open to the appropriate diameters. Remember: even though they are stacked on top of one another, the muscle and skin, that is, function independently. You may be fully able to open the skin to a fist size, though the underlying muscle simply cannot accommodate it or vice versa.

Successful engagements (more so minimizing anal fissures) stem from your mastery of not only your own anatomy, but also being able to analyze both successful and not-so-successful play routines. It’s totally a sport, and in order to get better, it requires practice, practice, practice! Through this play, your overlying skin gets tougher, allowing better elasticity and the underlying muscle to accommodate whichever size you desire. It’s not a hard concept; it just needs to be learned.

Full evaluation with the knowledge above leads to fruitful solutions and future engagements, whatever they may be.

Conclusion

Understanding anal fissures—what causes them, the symptoms they present, and how they can be treated and prevented—is essential for effective treatment and prevention. By recognizing early signs and knowing how to address them, you can help reduce the impact of these painful tears on your daily life.