Hemorrhoids are normal and everyone has them. Typically, when someone develops symptoms, this is what is referred to as hemorrhoids. There are internal and external hemorrhoids. Internal hemorrhoids are located inside the anal canal. External hemorrhoids are located just outside of the anus.

When hemorrhoids are functioning normally, we typically do not notice or feel them. When internal hemorrhoids become symptomatic, we typically will feel some itching, pressure or seepage from the prolapse. These symptoms are related to the hemorrhoid protruding through the anal canal. Bleeding associated with hemorrhoids is painless, so you should not feel anything. Thrombosed external hemorrhoids can be extremely painful and have an associated lump. Once they resolve, you may notice them when you wipe or examine yourself, but you typically do not “feel” them.

Fissures are usually caused by trauma to the inner lining of the anus. Hard, dry bowel movement is typically responsible for this condition. Chronic constipation or frequent diarrhea can also tear the skin around the anus. Other common causes of this condition include – straining during bowel movements/childbirth, reduced blood flow to the anorectal area, overly tight or spastic anal sphincter muscles.

Anal fissures can be either acute or chronic. Acute (recent onset) fissures may have the appearance of a simple tear in the anus. Chronic fissures, on the other hand, may have swelling and scar tissue present and may typically last for more than 8-12 weeks. Chronic fissures may be more difficult to treat and may also have an external lump associated with the tear (called a sentinel pile or skin tag) as well as an extra tissue just inside the anal canal, referred to as a hypertrophied papilla.

Pain and bleeding with bowel movements are typical symptoms of an anal fissure. Patients may experience severe pain during, and particularly after a bowel movement which may generally last for several minutes to a few hours. Other related symptoms include – bright red blood on the stool or toilet paper (after a bowel movement), a visible crack in the skin around the anus and a small lump or skin tag on the skin near the anal fissure.

Often, anal fistulas develop in relation to an anal abscess. That’s an infection that happens after an anal gland becomes clogged.

An anal fistula can develop while the infection is still active or after it resolves. Whether an abscess drains on its own or with the help of a doctor, there’s a risk of ending up with a fistula. According to some estimates, 40% to 50% of anal abscesses lead to anal fistula.

Even still, not all fistulas are associated with abscesses. Sometimes, they develop for unrelated reasons.

This is another name for an anal fistula. The two terms can be used interchangeably.

You can develop an abnormal tunnel called an anal fistula in your colorectal region. The tract originates in an anal gland and connects the anal canal to the skin of the buttocks.

A fistula can be classified as superficial, intersphincteric, transsphincteric, suprasphincteric or extrasphincteric, depending on the shape of the tract and which muscles it crosses.

Most cases of anal fissures do not require extensive treatment. Self-care remedies include increasing intake of fiber-rich foods, drinking more fluids, using over-the-counter stool softeners, applying a nitroglycerin ointment (to promote blood flow to the area), taking a sitz bath to relax the anal muscles and applying topical pain relievers such as lidocaine to help ease discomfort.

If any of the above non-surgical treatments do not improve your symptoms, physicians may recommend surgery as a final option. Physicians generally perform lateral internal sphincterotomy– a procedure which involves cutting a small portion of the anal sphincter muscle to reduce spasm and pain, and promote healing.

Diagnosis of an anal fissure starts with a medical history review and physical exam including a gentle inspection of the anal region. However, physicians will need to perform a rectal exam to confirm the diagnosis. 

Generally, the location of the fissure indicates about its causes. A fissure that occurs on the side of the anal opening (rather than the back or front) is more likely to be a sign of another disorder, such as Crohn’s disease. Physicians may recommend further tests like Flexible sigmoidoscopy and Colonoscopy, if they think that the patient suffers from other underlying conditions.

Your medical provider will start by performing a visual examination of your anal region. The fistula opening might be visible. For a look inside your anus, the doctor may use an anoscope.

The doctor may need to order additional tests. Imaging procedures like ultrasounds and MRIs can help the medical team identify where the fistula tract goes.

Because anal fistulas are associated with various medical diagnoses, your doctor may also want to test you for Crohn’s disease or another condition.