Hemorrhoid or anal fissure? How to tell them apart

A fissure and a hemorrhoid can both leave bright red blood on the paper. The pain is the splitter. An anal fissure is a small tear in the skin at the opening of the anus, and it usually hurts in a sharp, tearing way when you pass stool. A typical internal hemorrhoid bleeds with little or no pain.

The American Society of Colon and Rectal Surgeons patient guide on anal fissures says fissures are often confused with hemorrhoids, including by primary care clinicians, and that delay can turn a new tear into a chronic one ¹. In 2023 the society published its clinical practice guideline for the management of anal fissures, written for clinicians ². The steps below follow the society’s patient guide, which you can read in full, plus the trials that measured healing.

This page covers how the symptoms differ, how common each problem is, how each is treated, and why a short exam is more reliable than guessing from blood alone. If you want a symptom-by-symptom walk-through first, start with hemorrhoid symptoms.

How the pain and the bleeding differ

ASCRS describes the usual fissure story in plain terms. Pain is severe during a bowel movement and especially afterward, lasting from several minutes to a few hours. Blood is bright red, on the paper or on the stool. Between bowel movements, many people feel relatively fine. Some become afraid to go and try to hold stool in, which makes the next stool harder ¹.

The NHS anal fissure page uses the same three clues: severe sharp pain when you poo, burning pain afterward that may last several hours, and bright red blood in the toilet or on the paper. It also names piles as another cause of pain and bleeding, which is why the label matters ³.

Hemorrhoids follow a different pattern. The ASCRS hemorrhoid guide says painless rectal bleeding or tissue slipping out is the usual internal hemorrhoid story. Symptoms tend to build slowly and come and go. External hemorrhoids, when they hurt, are often a bluish lump just outside the anus. A clotted one, called a thrombosed hemorrhoid, is sudden and tender. External hemorrhoids that are not clotted are more about swelling, pressure, and trouble cleaning ⁵.

A clinic study of 807 people tested whether symptoms could predict the finding. Hemorrhoids were predicted by bleeding, weeping, and the absence of anal pain. Fissures were predicted by anal pain and by bleeding. Among people with a benign anal finding, 58.6% had bleeding, 53.7% had itch, 33.7% had pain, and 32.9% had burning ⁴. Pain with bleeding points toward a fissure. Bleeding without pain points toward a hemorrhoid. Itch shows up with both, so the pattern is only a clue.

How common each one is

Hemorrhoids show up often when someone looks. In a screening study of 976 adults, 38.93% had hemorrhoids, most of them grade 1, and 55.26% of those people reported no symptoms ⁶. Self-reported complaints are much lower, at 4.4% in a U.S. epidemiology study ⁸. ASCRS puts symptomatic hemorrhoids at roughly 5% of people, and says fewer than 10% of patients evaluated for them need surgery ⁵. A research review cites nearly 4 million U.S. office and emergency visits a year ⁹.

Anal fissure shows up often in clinic and much less often as a yearly rate. In a managed-care cohort from 2005 to 2011, there were 1,243 fissure cases. The overall incidence was 0.11% a year, or 1.1 cases per 1,000 person-years. It ranged from 0.05% in ages 6 to 17 to 0.18% in ages 25 to 34. Women made up 58% of cases and men 42%. Constipation was recorded in 14.2% of fissure patients versus 3.6% of matched controls ⁷. ASCRS says fissures can occur at any age. Its patient guide describes an equal split between men and women ¹. The population study found a different sex pattern by age: higher in females ages 12 to 24 and in males ages 55 to 64 ⁷.

A tear off to the side, more than one tear, a painless tear, or a tear that will not heal needs a look for other diseases, including Crohn’s disease, infection, and anal cancer ¹. The table above has the usual locations: about 85 to 90% at the back midline and about 10 to 15% at the front.

Why people mix them up

The symptoms overlap, and a lump is not specific. A chronic fissure, typically one lasting more than 8 to 12 weeks, can grow a sentinel pile, which is a skin tag at the outer end of the tear, plus a small swollen tag of tissue just inside, called a hypertrophied papilla ¹. That outside tag feels like a hemorrhoid when you wipe.

ASCRS says this mix-up is common, and that treating the wrong problem lets an acute tear become chronic and harder to heal ¹. Sandler and Peery’s review makes a broader point: bleeding, pain, itching, seepage, prolapse, and mucus were reported about as often by patients who did not have hemorrhoids as by patients who did ⁹. Blood on the paper is a reason for an exam, because the same spot of blood has more than one cause.

In the Kuehn clinic, almost one third (31.2%) of people with a benign anal finding had more than one. Skin tags were more common when another benign anal problem was present ⁴. A tag can be leftover from a hemorrhoid, a sentinel pile from a fissure, or both.

How an anal fissure is treated

Most fissures do not need surgery. Pain makes the internal sphincter spasm, blood flow to the tear drops, and the next stool hurts again. Treatment tries to break that cycle ¹.

For a new fissure, ASCRS starts with stool that is soft and formed: a high-fiber diet plus a supplement, totaling 25 to 35 grams of fiber a day. A stool softener and more water help if stools are hard. If stools are loose and frequent, an antidiarrheal may be needed instead. Lidocaine can numb the pain. Warm sitz baths for 10 to 20 minutes, several times a day and especially after a bowel movement, are meant to ease spasm. Opioid pain pills are a poor fit because they constipate. ASCRS says these measures can settle pain and bleeding and may heal more than half of acute fissures, with almost no side effects ¹.

The NHS anal fissure page says to see a GP if symptoms are worse or no better after 7 days of self-care. The GP asks what you feel and looks at the anus. If that exam is too painful, you may be referred for a look under anesthesia. Paracetamol or ibuprofen can help the pain in the meantime ³.

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Chronic fissures are harder. ASCRS says a surgeon may prescribe medicine that relaxes the internal sphincter, or may discuss a procedure if medical care fails ¹.

Nitroglycerin ointment relaxes that muscle and raises blood flow to the tear. In the patient guide, healing occurs in at least 50% of chronic fissures. Headache is the main side effect, reported in at least 20 to 30% of patients, and blood pressure can drop, especially if you already take blood pressure medicine. Recurrence is higher than after surgery ¹. A Cochrane review of non-surgical fissure therapy pooled the trials: glyceryl trinitrate (nitroglycerin) healed 48.9% versus 35.5% with placebo. Late recurrence was common, in the range of 50% of those who had healed. Calcium channel blockers and botulinum toxin were about as effective as nitroglycerin, with fewer adverse events. No medicine in those trials came close to surgical sphincterotomy for chronic fissures in adults, and the medicines were not tied to incontinence the way surgery can be ¹¹.

Topical diltiazem and nifedipine work in a similar way. ASCRS cites healing of chronic fissures in 65 to 95% of patients with these ointments, with headaches in up to 25%. Oral calcium channel blockers healed fewer fissures and caused more side effects than the topical forms ¹. A 2017 meta-analysis found calcium channel blockers more effective than nitroglycerin and less likely to cause headache, but graded that evidence as low quality. The one high-quality comparison was lateral internal sphincterotomy versus any medical therapy, favoring surgery for sustained cure (odds ratio of treatment failure 0.12). Across subgroups, incontinence after sphincterotomy was 3.4 to 4.4% ¹².

A 2023 meta-analysis used a looser definition of chronic (symptoms for at least 4 weeks, plus a sign such as a sentinel pile). Diltiazem beat glycerin for healing (relative risk 1.16). Nifedipine beat lidocaine for healing (relative risk 4.53) and for recurrence (relative risk 0.18). Botulinum toxin was not clearly better than glycerin or isosorbide dinitrate in that pooling ¹³. ASCRS still lists injection: about 50 to 80% full healing, with recurrence in up to 40%. Lateral internal sphincterotomy, a partial cut in the internal sphincter, has reported success over 90% when it is done carefully. The tradeoff is a chance of leaking gas or stool, so people who already leak, who have a birth injury to the sphincter, or who have Crohn’s disease need a careful talk first. Complete healing after medicine or surgery can take about 6 to 12 weeks ¹.

Fissures also come back after they heal, often after one hard stool. ASCRS says to keep the fiber habit even after the pain stops ¹. The NHS says a healing cream may be used for up to 8 weeks, and that an injection or a small cut in the muscle is the next step if creams and laxatives fail ³.

How a hemorrhoid is treated instead

Hemorrhoid care starts in a similar place and then splits. NIDDK’s home list is fiber, a stool softener, fluids, no straining, no long toilet sits, pain relievers, and warm soaks. Store-bought creams and suppositories are for mild outside pain, swelling, and itch, usually for about a week. Most prolapsed internal hemorrhoids, NIDDK says, go away without at-home treatment. Severely prolapsed or bleeding ones may need a procedure ¹⁴.

Bleeding or prolapsing internal hemorrhoids may be treated in the office with rubber band ligation, and only a doctor should place the band ¹⁴. Larger hemorrhoids are covered in hemorrhoid treatment. Timelines for flares that settle are in can hemorrhoids go away on their own.

Hydrocortisone, in the Jensen trial, healed many acute fissures, and baths plus bran relieved early pain sooner ¹⁰. If sharp pain is still there after a week of soft stools and baths, get an exam before you refill a steroid cream ³.

Why an exam settles it

ASCRS says most people who come in complaining of hemorrhoids still need a history and an exam before that label sticks ⁵. For a suspected fissure, the NHS says the GP looks at the anus, and a painful exam can be finished under anesthesia ^1,3.

Off-midline tears, several tears, painless tears, and tears that do not heal are the ones ASCRS flags for Crohn’s disease, infection, or a tumor ¹. The US Preventive Services Task Force recommends colon cancer screening starting at age 45 for adults at average risk ¹⁵. Bleeding hemorrhoids lists what bright red blood usually means.

The hemorrhoid symptom checker can sort home care from “get examined” before that visit. A first acute fissure still needs the basics: 25 to 35 grams of fiber, water, and warm soaks for 10 to 20 minutes after bowel movements. If the sharp pain is still there after a week, book the look ^1,3.