Anal fissure in women and men: how do sex and age change the picture?

Is anal fissure more common in men or in women?

Both sexes get anal fissures, and in clinic we see plenty of each. The good population studies do not give a clear, consistent winner, so we will not invent one. What is consistent is who tends to get them: young and middle-aged adults, people who strain with hard stools or have bouts of explosive diarrhea, and women around pregnancy and childbirth. Infants and young children are another common group.

The mechanism is the same in everyone: a stool stretches the anoderm beyond what it tolerates, the tear hurts, the internal sphincter tightens and the reduced blood flow keeps the tear open. If you want the full picture of that cycle, read What is an anal fissure? A surgeon explains it with a drawing of the anal canal and What causes an anal fissure? The tear, the spasm and the risk factors. Where sex and age matter is in where the fissure sits, why it appeared and how safe each treatment step is.

What is different about anal fissure in women?

Three things set women apart.

• Location. The back midline is still the usual site, but front-midline (anterior) fissures are seen more often in women than in men. The front of the canal is supported by a thinner layer of tissue, and childbirth can weaken it further. We go into this in Anterior anal fissure in women: why it happens and what changes in treatment.
• Pregnancy and childbirth. Constipation is very common in pregnancy: hormones slow the bowel, iron supplements harden stools and the growing uterus presses on the rectum. In a prospective cohort of 280 pregnant women, 43.9 % developed perianal disease, mostly in the third trimester, and constipation was by far the strongest risk factor (odds ratio 18.98). In that study, an isolated fissure was uncommon (0.71 %); hemorrhoids were the main problem (Poskus, BJOG 2014). After a vaginal delivery, pushing and perineal trauma can add a fissure in the following weeks. See All guides and All guides.
• Sphincter pressure. Most fissures sit on top of a tight internal sphincter. But some women, especially after childbirth, have a fissure with normal or even low sphincter pressure, sometimes with a hidden sphincter injury from delivery. The ACPGBI 2023 guideline gives these "low-pressure" fissures their own section.

The practical consequence is surgical caution. A lateral internal sphincterotomy divides part of the internal sphincter; in a woman whose sphincter is already weak, the risk of leaking gas or stool is higher. Before surgery, surgeons often check sphincter function (anal manometry, endoanal ultrasound) and may prefer botulinum toxin or other options. For creams, the choice during pregnancy and breastfeeding is covered in Which anal fissure cream is safe in pregnancy and while breastfeeding?.

What is different about anal fissure in men?

In men, the typical fissure is a back-midline tear with a high resting pressure of the internal sphincter. That is the classic picture the standard treatment ladder was built for: soft stools and sitz baths, then a sphincter-relaxing ointment (nifedipine, diltiazem or nitroglycerin) for 6 to 8 weeks, then botulinum toxin or lateral internal sphincterotomy if the fissure is still open.

Men are, on average, less likely to have hidden sphincter damage, so when surgery is needed, sphincterotomy is often a straightforward discussion; the details are in All guides. Men also tend to consult later. Many put up with pain and bleeding for months, assuming it is "just hemorrhoids", and arrive with a chronic fissure and a sentinel pile.

A front-midline fissure in a man is less common and deserves a careful look. So does any fissure off the midline, multiple fissures, or a painless ulcer, in either sex: these can be caused by Crohn’s disease or by infections such as syphilis, herpes or HIV-related ulcers, and the evaluation includes routine, confidential tests. We explain why in Lateral or multiple anal fissures: when should you think of Crohn’s, HIV, syphilis, tuberculosis or cancer?.

How is anal fissure different in babies and children?

Fissures are a common cause of bright red blood on the diaper or toilet paper in infants and toddlers. The trigger is almost always a hard stool: the move to solid food or cow’s milk, potty training, or a child who holds back because it hurts. That holding creates a cycle of harder stools and more pain.

The treatment is the stool, not the cream. In a randomized, placebo-controlled trial of 48 children aged 14 or younger, polyethylene glycol (an osmotic laxative) alone worked as well as polyethylene glycol plus topical diltiazem at 12 weeks (Alshehri, J Pediatr Surg 2020). The ACPGBI 2023 guideline also has a specific section on children. In practice: softening the stools with the pediatrician’s guidance, adequate fluids, fruit and vegetables, a calm toilet routine and, if needed, a barrier cream.

A fissure in a child that is off the midline, multiple, very large, or comes with diarrhea, poor growth or weight loss should be assessed by a pediatrician or pediatric gastroenterologist, because Crohn’s disease and other causes must be considered. For ointments and their limits in children, see Anal fissure in children: which creams help, which do not, and why the stool is the treatment.

What changes with anal fissure in older adults?

Fissures are less frequent after 60 or 70, and when they appear, the context is different:

• Causes: constipation from low mobility, low fluid intake and medicines (opioid painkillers, iron, some antacids and blood pressure drugs).
• Sphincter: resting pressure tends to fall with age, so a fissure on a weak sphincter is more likely. Sphincterotomy is approached with more caution, because continence reserve is lower.
• Bleeding: after 45, rectal bleeding must not be put down to a fissure without considering a colonoscopy, especially if the blood is mixed with stool or bowel habits have changed. Colorectal and anal cancers become more common with age.
• Healing: it can be slower, particularly with diabetes, smoking or poor nutrition.

Topical treatment follows the same principles as in younger adults, with attention to other medicines (for example, nitroglycerin ointment can lower blood pressure). More in All guides.

Does treatment change depending on sex and age?

The first steps are the same for almost everyone. What changes is how far and how soon to escalate.

Hydrocortisone creams, if used at all, should never be used for more than 7 days, at any age.

Which warning signs apply at any age?

Whatever your sex or age, see a doctor without delay if you notice:

Our page on causes of anal fissure and the postpartum fissure page go deeper into the most common situations.

Where does FISURIN fit?

FISURIN is a nifedipine and lidocaine hydrogel prescribed by the surgeons of Clínica Proctológica de Lima for adults with a chronic or post-operative fissure, with a written 6-week protocol. Our surgeons adapt its use to each patient: they decide individually during pregnancy and breastfeeding, they do not use it as the first step in children, where stool softening comes first, and in older adults they review other medicines beforehand. It does not replace soft stools, and it cannot promise closure in every case. FISURIN is a magistral formula prepared under prescription in Peru and is not shipped abroad; FISURIN Hydrogel and FISURIN Relief are in preparation, with a waiting list. See what is inside FISURIN or how to get it where you live.