Piles (hemorrhoids) or anal fissure? How to tell the difference

Piles (haemorrhoids, or hemorrhoids in US spelling) and an anal fissure are both common, and both often get better on their own. The NHS says piles often get better after a few days, and that an anal fissure usually gets better on its own too. They are easy to confuse, because both can bring bright red bleeding and pain around the anus, and both are linked to hard poo.

NICE's guidance for GPs (NICE CKS) even tells doctors to rule out a clotted pile when they think someone has a fissure, because it can show up in a similar way. This guide sets piles and an anal fissure side by side, explains the clues that help tell them apart, and says when to see a GP.

What is the difference between piles and an anal fissure?

Piles are swollen blood vessels in and around the anus, while an anal fissure is a small tear in the anus. NICE CKS describes a fissure as a tear or ulcer in the lining of the anal canal that causes pain when you poo, most often at the back of the anal canal, in the midline.

Piles (hemorrhoids) vs anal fissure: symptom by symptom

	Piles (haemorrhoids).	Anal fissure.
What it is	Swollen blood vessels: the cushions in the anal canal, enlarged	A small tear or ulcer in the lining of the anal canal
Pain	Often painless or mildly uncomfortable; can hurt badly if a clot forms or a pile comes down and gets trapped	Severe, sharp pain every time you poo, often followed by a burning pain for several hours
Bleeding	Bright red, usually painless; streaks on the paper, in the bowl or on the outside of the poo	When present, usually a small amount of bright red blood on the poo or the toilet paper
Lumps	Lumps around the anus; internal piles may come down when you poo	Not a main symptom; a long-lasting fissure may have a small skin tag at its end
Itching	An itchy anus is on the NHS list of symptoms	Not one of the main symptoms the NHS lists
Other signs	Mucus on your underwear or the paper; feeling you still need to poo	Some people describe a tearing feeling as the poo passes
Who gets it most	Most common between 45 and 65, in men and women	Most common between 15 and 40; men and women equally
How long it lasts	Often better after a few days; symptoms can come and go for a few days to a few weeks	Usually heals by itself; around half of new fissures heal within 6 to 8 weeks of self-care
NHS painkiller advice	Paracetamol; no ibuprofen if your piles are bleeding; no codeine	Paracetamol or ibuprofen

From the NHS, NICE CKS (guidance for GPs) and ACPGBI. These are typical patterns: the NHS says do not self-diagnose, and see a GP if you're worried.

You can have both at once, so look at the overall pattern. NICE CKS says the pain of a fissure comes every time you pass a poo, while the commonest sign of piles is bright red, painless bleeding, sometimes with an itch or a lump.

How can you tell if it's a fissure or a hemorrhoid?

Notice when and how it hurts. A fissure hurts sharply when you poo and can burn for hours afterwards, the NHS says, while ACPGBI says bleeding piles are either painless or only mildly uncomfortable, unless a clot forms (NICE CKS). ACPGBI adds that bright red blood with short-lived pain after passing a hard poo is highly likely to be a small tear.

Clues that point to a fissure:

• severe, sharp pain when you poo, which NICE CKS says comes every time; some people describe a tearing feeling
• a burning pain afterwards that may last for several hours (NHS)
• bright red blood with pain when pooing, often after constipation (NHS)

Clues that point to piles:

• bright red bleeding without pain, the most common symptom of piles (NICE CKS)
• an itchy anus, mucus on your underwear or toilet paper, or feeling like you still need to poo after going (NHS)
• a soft lump that comes down when you strain and goes back, or that you can gently push back inside (NICE CKS, NHS)

Treat these as clues only. The NHS says not to try to diagnose the cause of pain in your bottom yourself, and NICE CKS notes that a clotted pile can also cause pain, with or without bright red bleeding. To check for a fissure, a GP will ask about your symptoms and look at your anus, the NHS says.

What causes piles and anal fissures?

Hard poo and straining are linked to both, but the lists differ. The NHS says piles are more likely with constipation, pushing too hard when pooing, heavy lifting, getting older and being overweight. For a fissure, ACPGBI points to constipation and passing hard poo, or diarrhoea and passing frequent poo, though NICE CKS says many fissures have no link to either.

The NHS adds that you may be more likely to get an anal fissure if you have diarrhoea a lot, inflammatory bowel disease (such as Crohn's disease or ulcerative colitis), or a sexually transmitted infection such as syphilis or herpes.

Can you have piles and an anal fissure at the same time?

The two can occur together. A 2025 study in the journal Techniques in Coloproctology looked back at 171 people treated for advanced piles at a specialist unit in Turkey, and 48 of them also had an anal fissure. Those with a fissure had had symptoms for a shorter time, which the authors think was likely because the pain made people seek help sooner.

The study only covered people with advanced piles referred to one specialist unit, so it can't say how common the combination is in general. NICE CKS advises GPs examining someone for piles to check for other problems, such as fissures, at the same time.

Is a skin tag a pile or a sign of a fissure?

It can be linked to either, or to neither. ACPGBI says flaps of skin (tags) around the back passage are very common, are different from external piles, and are often what people call their piles. NICE CKS says a long-standing fissure may have a small skin tag at its end, and that skin tags can form after piles swell and clot repeatedly.

Warts can resemble skin tags too, NICE CKS notes. The NHS describes genital warts as small, rough lumps that can appear around the anus, and a common sexually transmitted infection. A sexual health clinic (NHS GUM clinic) can check lumps around the anus, and our guide to anal warts explains more. For the other lumps piles can be mistaken for, see what piles look and feel like.

What helps piles and a fissure at home?

Much of the self-care is the same. For both, the NHS advice is to drink lots of fluids and eat plenty of fibre to keep your poo soft, not to ignore the urge to poo, and to keep your bottom clean and dry. The differences are in the details, such as which painkillers to use and when to have a bath.

For piles, the NHS also suggests:

• gently pushing a pile back inside if you can
• an ice pack wrapped in a towel, or a warm bath to ease itching and pain
• paracetamol if piles hurt, but not ibuprofen if they're bleeding, and no painkillers that contain codeine
• cutting down on alcohol and caffeine, not pushing too hard when you poo, and not spending longer than you need on the toilet
• asking a pharmacist about creams, laxatives and cold packs

For a fissure, the NHS suggests:

• paracetamol or ibuprofen to help with pain
• a warm, shallow bath after you poo to ease the pain

If a fissure is not healing, the NHS lists laxatives, medicines to help with pain after you poo, and a cream you put on your anus to help it heal. ACPGBI names the two ointments commonly used: glyceryl trinitrate (GTN), which may give you a headache, and diltiazem, whose most common side effect is itching around the back passage. Our anal fissure guide covers these treatments, and our guide to piles in men covers piles treatments.

When should you see a GP?

See a GP if a fissure is getting worse or isn't better after 7 days of treating it yourself, or if piles are getting worse, not improving with home treatment, or keep coming back, the NHS says. Get any bleeding from your bottom checked too: the NHS says it is sometimes a sign of bowel cancer, which is easier to treat if found early.

For a fissure, the GP will ask about your symptoms and look at your anus. NICE CKS advises against a finger examination in general practice to diagnose a fissure, because it may be very painful. For piles, NHS inform says, the GP can examine your back passage to check for swollen blood vessels.

The NHS urgent signs:

• Ask for an urgent GP appointment or get help from NHS 111 if you have piles and a very high temperature or feel hot, cold or shivery and generally unwell, painless bleeding from the bottom, or pus leaking from your piles. The same goes for severe pain in your bottom with a high temperature, or black or dark red poo.
• Go to A&E or call 999 if you're bleeding non-stop from your bottom, there's a lot of blood (for example, the toilet water turns red) or you see large blood clots, or you have piles and severe pain.

See a GP, too, about changes in your poo that aren't usual for you, blood in your poo, losing weight without trying, or a lump in your tummy: the NHS lists these among the symptoms of bowel cancer. Our guide to bleeding from your bottom covers the signs in full.