Types of Anal Fissure: Does Every Fissure Need Surgery?

A Patient Guide to Anal Fissure Treatment in Agra

By Dr. Karan R. Rawat
MBBS, MS, FIAGES, FMAS, DMAS, FICRS, FALS, FISCP, FAIAS, MCLS, FCLS
Digestive • Liver • Pancreas • Colorectal & Advanced Surgery

Safe Gastro & Surgery Center (Agra Heart Center)
Church Road, Civil Lines, Agra
Appointment: 7398888889

Last medically reviewed: October 2026

“Doctor, I Have a Fissure. Will I Need Surgery?”

This is one of the most common questions asked by patients suffering from severe pain while passing stool.

The simple answer is:

No. Every anal fissure does NOT require surgery.

In fact, most acute anal fissures should initially be treated without surgery.

The American Society of Colon and Rectal Surgeons recommends non-operative treatment as the usual first-line approach for an acute anal fissure.

The important question is therefore not simply:

“Fissure hai—operation karana hai?”

The better questions are:

Is it an acute fissure or a chronic fissure? Why did it develop? Is the anal muscle in severe spasm? Has appropriate medical treatment already failed? Is this a typical fissure or could there be another underlying disease?

These factors determine treatment.

What Is an Anal Fissure?

An anal fissure is a small tear or split in the delicate lining of the anal canal.

The classic symptoms are:

  • very sharp pain while passing stool

  • burning pain continuing after stool

  • bright-red bleeding

  • fear of going to the toilet because of pain

  • constipation because the patient begins avoiding stool

  • occasionally a small skin tag when the fissure has been present for a long time

Anal fissures are different from piles or haemorrhoids, although both can sometimes cause bleeding during bowel movements.

Why Is Fissure Pain So Severe?

A fissure may appear to be only a small cut, yet the pain can be surprisingly severe.

There is an important mechanism behind this.

Hard stool or trauma

↓

Small tear develops

↓

Internal anal sphincter goes into spasm

↓

Anal pressure increases

↓

Blood supply to the fissure reduces

↓

Healing becomes difficult

↓

Next stool opens the fissure again

This creates what I often explain to patients as a:

“Pain–spasm–constipation cycle.”

Breaking this cycle is one of the main aims of fissure treatment.

Chronic anal fissures are particularly associated with increased internal sphincter tone and impaired local healing.

What Are the Types of Anal Fissure?

Anal fissures can be classified in several useful ways.

The most important distinction for treatment is between acute and chronic fissure.

Type 1: Acute Anal Fissure

An acute fissure is a recently developed fissure.

The ASCRS guideline generally defines acute fissure as symptoms present for less than six weeks.

It commonly develops after:

  • passage of a hard stool

  • constipation

  • excessive straining

  • an episode of severe diarrhoea

  • childbirth in some women

The fissure may look like a fresh superficial tear.

Does an acute fissure need surgery?

Usually, no.

Most acute fissures are initially managed conservatively.

Treatment aims to:

soften the stool + reduce trauma + reduce pain + allow the fissure to heal.

Type 2: Chronic Anal Fissure

A fissure that persists and develops features of chronicity is called a chronic anal fissure.

Chronic fissures may show features such as:

  • deeper fissure

  • exposed internal sphincter fibres

  • a skin tag called a sentinel tag

  • a hypertrophied anal papilla internally

  • repeated symptoms over weeks or months

  • recurrent pain after passing stool

These are recognised features of chronic fissure in colorectal guidelines.

A chronic fissure can become difficult to heal because the internal sphincter remains persistently tight.

Type 3: Primary or Typical Anal Fissure

Most fissures are primary fissures.

They are commonly associated with local trauma from stool combined with increased sphincter pressure.

A typical fissure is usually located in the midline, most commonly towards the back of the anus.

These fissures often respond well to conventional fissure treatment.

Type 4: Secondary or Atypical Anal Fissure

This group deserves special attention.

Some fissures are:

  • multiple

  • located away from the usual midline position

  • unusually shaped

  • associated with other symptoms

  • recurrent despite appropriate treatment

These are sometimes called atypical or secondary fissures.

They can occasionally be associated with underlying conditions such as:

  • Crohn's disease

  • tuberculosis

  • HIV infection

  • syphilis

  • certain haematological disorders

  • other inflammatory or infective conditions

The ASCRS guideline specifically advises considering alternative diagnoses when fissures are lateral or multiple.

This is important:

An unusual fissure should not simply be treated repeatedly with creams without considering why it is present.

Acute vs Chronic Fissure: What's the Difference?

Feature Acute Fissure Chronic Fissure
Duration Usually recent Persistent/recurrent
Appearance Fresh superficial tear Deeper established fissure
Sentinel skin tag Usually absent May be present
Muscle spasm May occur Often significant
Initial treatment Usually conservative Medicines first in many patients
Surgery Rarely first treatment Considered if appropriate treatment fails

The exact treatment must still be individualized.

Does Every Chronic Fissure Need Surgery?

Again:

No.

Even a chronic fissure does not automatically mean surgery.

Current colorectal guidelines support several non-operative treatments for chronic anal fissure before or instead of surgery in appropriately selected patients.

Management may progress through several steps.

Step 1: Correct the Stool Problem

Without correcting constipation, simply putting an ointment over the fissure may not solve the underlying problem.

The aim is:

Soft, formed and easily passed stool.

Treatment may include:

  • adequate fluids

  • appropriate dietary fibre

  • fruits and vegetables

  • fibre supplements when appropriate

  • stool softeners or laxatives when prescribed

  • avoiding excessive straining

Both constipation and repeated diarrhoea can contribute to anal fissure formation.

Step 2: Warm Sitz Bath

Sitting in comfortably warm water can provide symptomatic relief and may help relax the anal area.

It should not be excessively hot.

A sitz bath is supportive treatment—it does not replace correction of constipation or medical therapy where required.

Step 3: Medical Treatment to Relax the Anal Muscle

In chronic fissures, an important part of treatment involves reducing internal sphincter spasm.

Medicines may include topical preparations containing agents such as:

Diltiazem

or

Glyceryl trinitrate / GTN

These medicines help reduce sphincter pressure and create better conditions for healing.

Current ASCRS guidance supports both topical nitrates and topical calcium-channel blockers for chronic anal fissures, with calcium-channel blockers generally having fewer side effects such as headache.

These medicines should be used under medical guidance.

What Happens If Medicines Do Not Work?

This is where treatment becomes more individualized.

Options may include:

Botulinum toxin injection

or

Surgical treatment

Botulinum toxin temporarily relaxes the sphincter muscle and may allow the fissure to heal.

According to ASCRS guidance, botulinum toxin has results comparable with topical treatment as first-line therapy for chronic fissure and may provide modest benefit as second-line therapy after failure of topical treatment.

When Might Surgery Be Considered?

Surgery may be discussed when a patient has situations such as:

  • persistent chronic fissure

  • significant sphincter spasm

  • severe recurrent pain

  • repeated reopening of the fissure

  • failure of appropriate conservative treatment

  • failure of topical medicines

  • selected recurrent fissures

  • significant effect on quality of life

But the decision should be individualized.

What Is Lateral Internal Sphincterotomy?

Lateral Internal Sphincterotomy (LIS) is an established operation for appropriately selected patients with chronic anal fissure.

A controlled portion of the internal anal sphincter is divided.

This decreases excessive sphincter pressure.

The principle is:

High sphincter pressure
↓
Controlled reduction of pressure
↓
Improved blood flow
↓
Reduced spasm
↓
Fissure heals

LIS has high healing rates, but because the anal sphincter contributes to continence, patient selection and surgical technique are important.

Does Fissure Surgery Cause Loss of Bowel Control?

This concern should be discussed openly rather than ignored.

Any procedure that permanently divides part of the sphincter carries some risk of changes in continence.

This is why a fissure operation should not be performed casually in every patient.

Modern surgical strategy emphasizes appropriate patient selection and limiting sphincter division to what is necessary.

The ASCRS guideline reports that a tailored sphincterotomy, where division is limited according to fissure length, can provide similar healing with a lower risk of faecal incontinence than a more extensive traditional sphincterotomy.

Who Needs Extra Caution Before Sphincterotomy?

A surgeon may take particular care when considering sphincter-dividing surgery in people with factors such as:

  • previous anal surgery

  • pre-existing difficulty controlling gas or stool

  • previous sphincter injury

  • obstetric sphincter injury

  • inflammatory bowel disease

  • reduced sphincter tone

In selected situations, sphincter-preserving treatment may be preferred.

This is another reason why there is no single operation suitable for every fissure patient.

What About Laser Treatment for Anal Fissure?

Patients frequently search online for:

“Laser fissure treatment in Agra”

or

“Laser surgery for fissure.”

Laser technology can be used in selected proctology procedures and some surgical techniques marketed for fissure management.

However, patients should understand an important principle:

The aim is not simply to use a laser—the aim is to correct the reason why the fissure is failing to heal.

For a chronic fissure, this may involve addressing:

  • constipation

  • repeated trauma

  • sphincter spasm

  • associated sentinel tag

  • underlying inflammatory disease

  • another anorectal condition

International colorectal guidelines continue to regard established medical therapies, botulinum toxin and appropriately selected lateral internal sphincterotomy as core evidence-based options for chronic anal fissure.

Therefore:

“Laser” should not be considered automatically better or automatically necessary for every fissure.

The procedure should be selected according to the individual patient's anatomy and disease.

Can the Sentinel Tag Simply Be Removed?

A chronic fissure may develop a small skin tag at its outer end.

Many patients think:

“Doctor, बस इस मस्से को काट दीजिए.”

But the tag may be only a result of the chronic fissure.

Removing a skin tag without treating the underlying fissure, sphincter spasm or constipation may not address the actual problem.

The fissure itself must be properly evaluated.

Fissure vs Piles: They Are Not the Same

Patients frequently confuse the two.

Anal fissure

Typically causes:

Severe cutting or burning pain during and after stool + bright red bleeding

Piles

More commonly cause:

Bleeding, prolapse/swelling, mucus or irritation, although pain can occur in certain haemorrhoidal complications.

A patient can also have both piles and fissure at the same time.

Correct diagnosis therefore matters before treatment.

When Should You See a Doctor for Fissure?

Seek medical evaluation when:

  • pain during stool is severe

  • bleeding continues

  • symptoms recur repeatedly

  • symptoms persist despite treatment

  • constipation is persistent

  • a skin tag has developed

  • there is pus or swelling

  • there is fever

  • there are multiple fissures

  • the fissure is located unusually

  • you have unexplained weight loss or chronic diarrhoea

  • there is concern about Crohn's disease or another bowel disorder

Severe anal pain with fever or systemic illness can indicate another condition such as an abscess and deserves prompt assessment.

Frequently Asked Questions About Anal Fissure

Can an anal fissure heal without surgery?

Yes.

Many acute fissures heal with conservative treatment, stool regulation and appropriate medical therapy.

How do I know if my fissure has become chronic?

Persistent symptoms over several weeks, recurrent episodes, a deeper fissure, sentinel tag or exposed internal sphincter may suggest chronicity.

A clinical examination can usually establish the diagnosis.

Does chronic fissure always require surgery?

No.

Topical medicines and, in selected cases, botulinum toxin can be tried.

Surgery is generally considered when conservative treatment is unsuccessful or when the patient's clinical situation makes surgery the more appropriate option.

Why does my fissure keep returning?

Common reasons include:

  • recurrent constipation

  • hard stools

  • excessive straining

  • persistent sphincter spasm

  • incomplete healing

  • repeated diarrhoea

  • occasionally an underlying bowel disorder

Finding and treating the cause is important.

Is fissure caused only by constipation?

No.

Constipation is a common cause, but persistent diarrhoea can also trigger fissures. Other medical conditions may occasionally produce secondary fissures.

What is the best treatment for fissure?

There is no single treatment that is best for every patient.

An acute fissure, chronic fissure, recurrent fissure and an atypical fissure may all require different approaches.

The correct treatment depends upon:

type of fissure + duration + sphincter spasm + bowel habits + previous treatment + continence status + underlying disease

Fissure Treatment in Agra

Patients looking for evaluation of:

Pain During Stool | Anal Fissure | Chronic Fissure | Recurrent Fissure | Sentinel Tag | Constipation | Piles | Fistula | Perianal Abscess | Pilonidal Sinus

can consult:

Dr. Karan R. Rawat

Digestive • Liver • Pancreas • Colorectal & Advanced Surgery

Safe Gastro & Surgery Center

Agra Heart Center, Church Road, Civil Lines, Agra

Appointment: 7398888889

Patients also visit from Mathura, Vrindavan, Govardhan, Farah, Firozabad, Tundla, Shikohabad, Etmadpur, Fatehabad, Kiraoli, Kheragarh, Bharatpur, Dholpur, Hathras, Etah, Mainpuri, Aligarh, Gwalior, Morena and nearby regions.

Final Message: Fissure Does Not Automatically Mean Surgery

The most important message for patients is:

Acute fissure → usually start with conservative treatment.

Chronic fissure → medicines can still work.

Persistent chronic fissure → Botox or surgery may be considered.

Atypical fissure → investigate the underlying cause.

So if you have been diagnosed with an anal fissure, do not immediately assume:

“अब ऑपरेशन ही होगा.”

Equally, a chronic fissure that has been causing severe symptoms for months should not necessarily be treated indefinitely with temporary pain-relief creams without reassessment.

The aim should always be:

Identify the type → understand the cause → correct bowel habits → relax sphincter spasm → choose surgery only when genuinely indicated.

Clear diagnosis. Right treatment. Surgery only when needed.

Medical Disclaimer

This article is intended for patient education and general health awareness. Anal pain and rectal bleeding can have causes other than fissure. Diagnosis and treatment should be based on individual clinical examination and medical history.