# Acute anal fissure - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: ASCRS Clinical Practice Guideline for Anal Fissure 2017 · Xyloproct (lidocaine 5%) ointment SmPC sections 4.2 and 4.4 (eMC product 883) - Verified date: 2026-08 ## Verified against - ASCRS Clinical Practice Guideline for Anal Fissure 2017 - Xyloproct (lidocaine 5%) ointment SmPC sections 4.2 and 4.4 (eMC product 883) - Acute anal fissure - disease-level clinical article (anal-fissure-clinical.txt) ## Treatment metadata - Glyceryl trinitrate — topical - Referral & safety-netting (no drug therapy) - Lidocaine — topical ## Complete treatment card ```text ACUTE ANAL FISSURE Sources: ASCRS Clinical Practice Guideline for Anal Fissure 2017 · Xyloproct (lidocaine 5%) ointment SmPC sections 4.2 and 4.4 (eMC product 883) Review status: REVIEWED against ASCRS Clinical Practice Guideline for Anal Fissure 2017, Xyloproct (lidocaine 5%) ointment SmPC sections 4.2 and 4.4 (eMC product 883), Acute anal fissure - disease-level clinical article (anal-fissure- clinical.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (4) - Acute fissures cause severe pain during bowel movements along with minor blood streaking rather than heavy bleeding [anal pain] - Pain often continues for hours after the bowel movement is over [anal pain] - Chronic fissures cause prolonged, recurring painful defecation with intermittent rectal bleeding, often with constipation or hard stools [constipation · rectal bleeding] - Crohn disease can cause recurring anal pain tied to defecation over a long period [anal pain] SIGNS - what you find (6) - An acute fissure looks like a shallow, lengthwise tear extending up from the anal opening - Both the fissure and the anal sphincter are typically very tender to touch - Chronic fissures are larger and deeper, sometimes exposing the internal sphincter muscle fibers - Repeated injury and healing leave thickened, indurated edges forming a skin tag known as a sentinel pile - The classic triad in chronic disease is a sentinel skin tag, the fissure itself, and an enlarged anal papilla - Fissures in the midline, front or back, are typical, while an off-midline location is atypical TESTS (1) - Examination under anesthesia may be used for chronic, recurring fissures to confirm the diagnosis and sometimes treat it at the same time IF NOT THIS - what else fits (6) - Hemorrhoids are the most common condition confused with a fissure - Pain is usually confined to external hemorrhoids, especially when clotted - A perianal abscess can also cause pain that worsens with defecation, sometimes with bleeding - An abscess can progress into an anal fistula with bleeding or pus discharge - Perianal ulcers from STIs, inflammatory bowel disease, or tuberculosis are additional considerations - Solitary rectal ulcer syndrome can mimic fissure symptoms and is usually found further up from the anal opening on sigmoidoscopy Source StatPearls "Anal Fissures" - disease-level clinical article Status traced to the source above 1. GLYCERYL TRINITRATE [1st line] Adult Apply 0.4% ointment intra-anally every 12 hours x up to 8 weeks Peds Specialist pediatric surgical referral required Source ASCRS Clinical Practice Guideline for Anal Fissure 2017 Why Topical nitrate that relaxes the internal anal sphincter and improves local blood flow, breaking the spasm-ischemia cycle that keeps a fissure from healing; used alongside fiber, stool softeners, and sitz baths rather than instead of them. Caution Headache is very common due to systemic nitrate absorption. Advise high-fiber diet, stool softeners, and warm sitz baths concurrently. Contraindicated with PDE-5 inhibitors (sildenafil). Egypt GLYCEROTONE 0.4 % RECTAL OINT. 50 GM EGPI > MISR 32.50 EGP RECTOSWAB RECTAL OINT 30 GM UNISWAB 12.90 EGP 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Acute anal fissure - disease-level clinical article (anal-fissure-clinical.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - An atypical (nonmidline) fissure location requires investigation for secondary underlying causes (Crohn disease, infection, malignancy). 3. LIDOCAINE [2nd line] Adult Apply 5% ointment topically to anal verge prior to defecation x up to 2 weeks Peds Specialist pediatric surgical referral required Source Xyloproct (lidocaine 5%) ointment SmPC sections 4.2 and 4.4 (eMC product 883) Why Topical local anesthetic that numbs the anal verge to ease the pain of defecation; provides symptomatic relief only and does not address the sphincter spasm that perpetuates the fissure. Caution Symptomatic pain relief option; does not heal internal sphincter spasm. A fissure is broken mucosa and lidocaine crosses it. Stay under about 6 g of ointment a day; past that the drug reaches the blood, and in children that has caused seizures. Discontinue if local sensitization occurs. Egypt FARCO-CAINE 5% OINT. 20 GM PHARCO 4.25 EGP LIDOSINE 5% TOPICAL OINT. 20 GM AMRIYA 4.40 EGP LIDOGED 5% TOPICAL GEL 15 GM JEDCO INT. CO... 5.00 EGP ULTRACAINE 5% GEL 30 GM MEMPHIS 31.00 EGP XYLOTOP 4% TOP. CREAM 20 GM SIGMA 4.25 EGP XYLOTOP 4% TOPICAL GEL 20 GM SIGMA 5.00 EGP LIDOCAINE 2% GEL. 20 GM ALEXANDRIA 6.75 EGP XYLOCAINE JELLY 2% 30 GM ASPEN PHARMA ... 30.80 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)