Why do fissures and anal pain show up in pregnancy?
Pregnancy changes the bowel in ways that are perfect for tearing the anal lining. Progesterone slows the gut, iron supplements harden the stool, nausea reduces how much you drink, and in the third trimester the uterus presses on the rectum and the pelvic veins. The result is hard stools and straining, which is exactly what splits the anoderm, the thin skin of the lower anal canal.
The best data we have come from a prospective cohort that followed 280 women through pregnancy and after delivery: 43.9 % developed perianal disease, mostly late in pregnancy, and constipation was by far the strongest risk factor (odds ratio 18.98) (Poskus, BJOG 2014). Most of that disease was hemorrhoids; an isolated fissure was seen in only 0.71 %. Two practical lessons follow. First, if you control constipation you prevent most of the problem. Second, not every painful bottom in pregnancy is a fissure, so a short examination by your obstetrician, midwife or a colorectal surgeon is worth it before you buy anything.
A fissure has a typical story: a sharp, cutting pain during the bowel movement that can last minutes to hours afterwards, and a little bright red blood on the paper. Swelling, a soft lump or itching without much pain point more towards hemorrhoids. Our guide on All guides walks through the trimesters one by one.
What should you do first, before any cream?
In pregnancy we apply the same logic as in any acute fissure, with even more weight on the basics, because they are effective and carry practically no risk for the baby. A classic randomized study of first-episode acute fissures found that 87 % healed at 3 weeks with warm sitz baths plus bran, against 60 % with lidocaine ointment alone (Jensen, BMJ 1986). The stool mattered more than the cream.
- Fiber, built up gradually. Psyllium (ispaghula) is the usual choice in pregnancy because it is not absorbed. Start with a small dose and increase over 1 to 2 weeks to avoid bloating. Our guide to All guides explains how.
- Water. Fiber without water makes stools bulkier, not softer. Drink regularly through the day, more if you are vomiting or it is hot.
- A gentle stool softener if fiber is not enough. Osmotic laxatives such as lactulose or macrogol (polyethylene glycol) act inside the bowel and are commonly used in pregnancy; ask your obstetrician or pharmacist which one and how much. Avoid buying stimulant laxatives on your own.
- Warm sitz baths. Sit in plain warm water for 10 to 15 minutes after bowel movements. It relaxes the sphincter and cleans without rubbing. No salts, oils or soaps are needed. See All guides.
- Toilet habits. Go when you feel the urge, do not strain, and do not sit on the toilet scrolling. A small footstool under your feet straightens the anorectal angle.
If iron tablets are clearly making you constipated, mention it: sometimes the dose or the type can be adjusted.
Which fissure creams are usually acceptable in pregnancy?
For symptom relief while the stools do their work, two groups of products are the usual choice. Neither closes a chronic fissure, but both make bowel movements bearable, and that alone stops the cycle of fear, holding back and harder stools.
| Product type | What it does | How it is usually used in pregnancy | Watch out for |
|---|---|---|---|
| Barrier creams (zinc oxide, petroleum jelly) | Protect the skin and lubricate the passage of stool | A thin layer before and after bowel movements | Fragrance or added ingredients that irritate |
| Topical lidocaine (gel or ointment) | Numbs the tear for a while | A small amount just before the bowel movement, for a short period | Local irritation or allergy; do not apply large amounts many times a day for weeks |
| Hydrocortisone (mild steroid) | Calms itching and inflammation | Only if a doctor recommends it, for a few days | Thins the skin and slows healing; never more than 7 days |
| Hemorrhoid combination creams | Mix anesthetic, vasoconstrictor and sometimes steroid | Ask before using; check every ingredient | Do not relax the sphincter, so they do not close a fissure |
Always tell the pharmacist you are pregnant and read the full ingredient list: many "hemorrhoid" products contain a steroid or a vasoconstrictor that you may not want to use for long. We explain the differences ingredient by ingredient in Over-the-counter fissure creams compared: what each ingredient can and cannot do, and why these products do not close a fissure in Why hemorrhoid creams do not close an anal fissure (and what does).
Can you use nifedipine, diltiazem or nitroglycerin while pregnant?
This is the question that matters most and the one with the least data. Topical sphincter relaxants are the first-line treatment for a chronic fissure in adults, used two to three times a day for 6 to 8 weeks. But pregnant women are excluded from almost every fissure trial, so there is no solid evidence on their safety for the baby, and no solid evidence that they are harmful either.
The ACPGBI 2023 guideline, the most recent British guideline on anal fissure, deals with pregnancy and breastfeeding in a separate section, precisely because the usual algorithm cannot be applied unchanged. In practice, this is how colorectal surgeons approach it:
- Most fissures in pregnancy are acute and settle with soft stools, sitz baths and a short course of a soothing cream. A relaxant is often not needed.
- If a fissure becomes chronic or the pain is severe, the treating doctor weighs the stage of pregnancy, the intensity of symptoms and the available options, ideally together with the obstetrician. Whether to prescribe a relaxant, which one and for how long is decided for that woman, not from a general rule.
- Nitroglycerin causes headache in up to half of patients and can make you dizzy, which is worth knowing when blood pressure already changes in pregnancy.
- Botulinum toxin and lateral internal sphincterotomy, the next steps for a fissure that will not heal, are usually postponed until after delivery.
So do not start a relaxant ointment you have at home or that a friend recommends, and do not assume it is forbidden either. Ask the doctor who is following your pregnancy, with the colorectal surgeon if needed.
What changes when you are breastfeeding?
Many fissures appear in the weeks after delivery, when the first bowel movements are feared, iron and painkillers constipate, and the pelvic floor is sore. The basics are the same: fiber, water, a softener and sitz baths. Barrier creams and short-term topical lidocaine are the usual relief.
The difference is that the baby is now exposed only through breast milk, not through the placenta. The amount of medicine absorbed from a thin layer of ointment on the anal canal is small, and many doctors are more comfortable prescribing a sphincter-relaxing ointment during breastfeeding than during pregnancy. Even so, the decision belongs to your doctor, who will check the specific drug, the dose and the age of your baby. Hydrocortisone keeps the same rule: never more than 7 days.
We cover the post-delivery fissure in detail in All guides and on our page about fissures after childbirth.
What should you avoid in pregnancy?
- Self-prescribed steroid creams for weeks. The 7-day limit on hydrocortisone does not change because you are pregnant.
- Leftover prescription ointments from a previous fissure, or one prescribed for someone else.
- Stimulant laxatives bought on your own as a daily habit, and enemas without advice.
- Essential oils, vinegar, garlic or alcohol-based products on the anal canal: they burn a raw tear. The evidence for "natural" ointments is reviewed in Aloe, calendula, coconut oil, honey: what does the evidence say about natural remedies for anal fissure?.
- Holding back the urge because you fear the pain: the stool gets harder and the next bowel movement tears more.
When should a pregnant woman with anal pain see a doctor without delay?
A typical fissure is a midline tear that hurts during and after bowel movements and bleeds a little bright red blood. Get checked without delay if the picture is different:
- Heavy bleeding, clots, or blood mixed with the stool.
- Fever, pus or a hot, painful swelling next to the anus (possible abscess).
- A hard, very painful lump at the anal edge (often a thrombosed hemorrhoid, which can be treated).
- A fissure off the midline, several fissures at once, or a lump that keeps growing.
- Weight loss, a change in bowel habit lasting weeks, or bleeding after the age of 45 that has never been investigated.
- No bowel movement for several days despite softeners, with abdominal pain.
If a fissure is still open 6 to 8 weeks after delivery despite good stool habits, it has become chronic and deserves a colorectal assessment: see our treatment page.
Where does FISURIN fit?
FISURIN contains nifedipine, a sphincter relaxant, with lidocaine in a water-based hydrogel. For that reason we do not recommend it as self-treatment in pregnancy: whether it is appropriate during pregnancy or breastfeeding is decided by the treating surgeon together with the obstetrician, case by case. In many women the right plan is soft stools and a barrier cream first, and a relaxant only if the fissure becomes chronic, often after delivery. FISURIN does not replace soft stools and does not promise closure in every case.
Today FISURIN is a magistral formula prepared under prescription in Peru; it is not shipped abroad. FISURIN Hydrogel and FISURIN Relief are in preparation, with a waiting list by country. See what is inside FISURIN or how to get it where you live.
Frequently asked questions
Is lidocaine cream safe for an anal fissure in pregnancy?
A small amount of topical lidocaine before bowel movements, for a short period, is the usual symptom relief in pregnancy. Check the product with your doctor or pharmacist and avoid large amounts many times a day for weeks.
Can I use hydrocortisone for a fissure while pregnant?
Only if a doctor recommends it, and never for more than 7 days. It calms itching and inflammation but thins the skin and slows healing.
Is nifedipine ointment safe during pregnancy?
There are no solid safety data, because pregnant women are excluded from the trials. It is neither routine nor automatically forbidden: your treating doctor decides, usually after soft stools and sitz baths have been tried.
Which laxative can I take for a fissure while pregnant?
Psyllium fiber is the usual first step; if it is not enough, osmotic softeners such as lactulose or macrogol are commonly used. Ask your obstetrician or pharmacist for the product and dose.
Will a fissure in pregnancy go away after delivery?
Most acute fissures heal with soft stools within weeks. If it is still open 6 to 8 weeks after delivery, it is chronic and needs a colorectal assessment.