When should I consider referring a patient with an anal fissure to a specialist?

Consider referring a patient with an anal fissure to a specialist in the following situations:

• If rectal cancer is suspected, refer urgently using a suspected cancer pathway for an appointment within 2 weeks.
• If another serious underlying cause is suspected, such as inflammatory bowel disease or a sexually transmitted infection (e.g., HIV), refer to an appropriate specialist with urgency based on clinical judgement.
• If the anal fissure appears atypical on examination, consider specialist referral.
• Consider referral to a general or colorectal surgeon if the anal fissure occurs in an elderly person, as primary anal fissures are uncommon in this group and serious pathology should be considered.
• For adults with a primary anal fissure that has not healed after 6–8 weeks of conservative management, consider specialist referral.
• In children, advise parents/carers to seek specialist advice if the fissure is unhealed after 2 weeks or earlier if there is significant pain.

For all patients, ensure initial management with stool softening, lifestyle advice, and pain control before considering referral unless serious pathology is suspected.

Summary: Urgent referral is needed if cancer is suspected; otherwise, refer if fissure is atypical, secondary causes are suspected, fissure is persistent beyond standard treatment duration, or in elderly patients.

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