Hemorrhoids & Anal Fissure
Common and treatable causes of bleeding or pain when passing stool. Most cases respond beautifully to simple measures at home — surgery is rarely needed.
Category
Common
Red flags
4
This article is educational and does not replace your doctor's advice. Seek urgent care for any red-flag symptoms.
What is it?
Hemorrhoids are swollen veins inside or just outside the anus. Internal hemorrhoids (above the dentate line) usually bleed without pain. External hemorrhoids (below) can be painful when they thrombose (blood clot inside).
Anal fissure is a small tear in the anal lining, usually from a hard stool. It causes sharp pain during and after bowel movements, and a small streak of blood.
How common is it?
Hemorrhoids affect at least 50% of adults at some point. Anal fissures are also very common — often after pregnancy, childbirth, or chronic constipation. Both peak in 30s-50s.
Why does it happen?
Pressure from straining, constipation, prolonged sitting, pregnancy, chronic diarrhea, low-fiber diet, heavy lifting. Genetic predisposition for hemorrhoids. Anal fissures usually start with a hard stool that tears the lining; the pain causes spasm of the anal muscle, which prevents healing.
Symptoms
- Bright red blood on toilet paper or in the toilet bowl after bowel movement
- Itching or irritation around the anus (hemorrhoids)
- Sharp, knife-like pain during and after bowel movement (fissure)
- Visible lump or tenderness around anus (thrombosed external hemorrhoid)
- Mucus discharge
- Sensation of fullness or "something coming out" (prolapsing internal hemorrhoid)
Red flags — seek urgent medical care
Heavy or dark blood (not bright red)
Could be more proximal source — needs colonoscopy.
Change in bowel habits or weight loss
Investigate for cancer.
Persistent bleeding despite treatment
Need formal evaluation.
Severe persistent pain not relieved by usual measures
Could be abscess or thrombosed hemorrhoid needing intervention.
How is it diagnosed?
Diagnosis is usually clinical. Your doctor will inspect the anus, perform a digital rectal exam, and may do anoscopy (a short scope) to see internal hemorrhoids. Colonoscopy is recommended for: any patient over 45 with rectal bleeding, anyone with red-flag symptoms, or unclear bleeding source.
Outlook — what to expect
Excellent. >90% of hemorrhoids and fissures resolve with conservative treatment within 4-8 weeks. Recurrence is common if the underlying cause (constipation, straining) is not addressed.
Treatment
Habits & Lifestyle
Stop the cycle: prevent constipation, prevent straining.
- Sitz baths — sit in warm water for 10-15 minutes 3-4 times daily, especially after bowel movements.
- Don't strain or push too hard — use a footstool to raise knees.
- Limit toilet time to 5 minutes.
- Wipe gently with soft, unscented wipes or rinse with water.
- Avoid prolonged sitting at work — get up every hour.
Diet
Soft regular stools are the goal.
- 25-30 g fiber daily.
- 1.5-2 liters of water daily.
- Add psyllium (Metamucil) — strongly evidence-based for hemorrhoids.
- Avoid spicy food during flares — increases burning sensation.
Medications
Topical and oral options.
- Topical hydrocortisone or lidocaine creams — short-term for symptom relief.
- Topical glyceryl trinitrate (GTN 0.4%) or diltiazem — heal anal fissures by relaxing the anal muscle. 60-80% effective.
- Stool softeners (PEG, lactulose) to prevent recurrence.
- Pain relief: paracetamol; AVOID NSAIDs and aspirin which can worsen bleeding.
- Phlebotonics (diosmin) — modest benefit for hemorrhoids.
Procedures & Surgery
Office procedures and surgery for severe cases.
- Rubber band ligation — office procedure for grade II-III internal hemorrhoids; very effective.
- Sclerotherapy or infrared coagulation — alternatives for grade I-II.
- Botulinum toxin injection for chronic anal fissure not responding to GTN.
- Hemorrhoidectomy — surgery for severe (grade IV) or thrombosed external hemorrhoids.
- Lateral internal sphincterotomy — gold standard surgery for chronic anal fissure.
Questions to ask your doctor
Save this list or print it before your appointment — doctors appreciate prepared patients.
- Do I need a colonoscopy or is this just hemorrhoids?
- What grade are my hemorrhoids?
- Should I try GTN cream for my fissure?
- When is surgery needed?
Medically reviewed by: SGA Patient Education Panel · Last reviewed 24/04/2026