Executive summary
- Typical: sharp anal pain during/after defaecation ± small bright red bleed; often constipation-related.
- First-line: stool-softening + local measures; add topical vasodilator therapy for persistent symptoms.
- Reassess/consider referral if off-midline fissure, systemic symptoms, ongoing bleeding, or poor response.
Assessment and red flags
- Inspect perianal area; DRE/proctoscopy only if clinically needed and tolerated.
- Red flags: off-midline/multiple fissures (IBD/infection/malignancy), weight loss, change in bowel habit, IDA, palpable mass, immunosuppression.
Management (primary care)
- Stool-softening: macrogol (titrate) ± short stimulant course; fibre/fluids; warm baths; avoid straining.
- Analgesia: paracetamol ± topical local anaesthetic short-term; avoid constipation-inducing opioids where possible.
- Topicals: GTN 0.4% (headache common) or topical diltiazem where used locally (often off-label) — follow local formulary and counsel re side effects/interactions.
When to refer
- Urgent: suspected abscess/systemic illness, significant bleeding, or cancer red flags per local pathways.
- Routine: persistent symptoms after structured conservative + topical therapy (often 6–8 weeks), recurrent fissure, diagnostic uncertainty.
Frequently asked questions
Do fissures need antibiotics?
Not if uncomplicated. Consider infection only with discharge, fever, marked swelling, or immunosuppression.
How long does healing take?
Many acute fissures improve within days–weeks with stool-softening. Persistent symptoms benefit from topical therapy and reassessment.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.