Saturday, August 11, 2007

Pain in the Ass


I suppose the greatest satisfaction for a surgeon is taking on a big and challenging case, carrying it out perfectly even when encountering difficulties, and having it turn out well. Saving a life in the process -- understood. And yet it might be that the most grateful patients I've ever had are those on whom I performed an embarrassingly simple operation -- one that takes only a minute or two. These patients, often, came (or were helped) into my office crying, begging, "Doc, if you can't help me, could you please kill me?"

In my previous post I suggested the anus could stand a little re-design. How nice it would be to download (as it were) version 2.0. Maybe it could come with a user's guide, too; and not just for the owners (it could be brief: Fiber. And lube. But I digress). A shop manual would be nice, because it's actually surprisingly misunderstood by lots of primary docs. (Also brief: hemorrhoids protrude, and bleed. If there's lots of pain involved, it's something else.) (Oh, yeah: "thrombosed hemorrhoid" -- which can indeed hurt like hell -- is another of those misnomers. "Peri-anal hematoma" is more apt. But that's not what I'm talking about.)

I'd guess most people (maybe not vegetarians) have had one of those bowel movements that brings tears to the eyes. A small tear of the skin overlying the sphincter muscle (control muscle) may occur on such an occasion. When it does, then things go in one of two directions: with time and luck and perfection of stoolage, it heals. Or it doesn't. The tear deepens, exposing the muscle underneath. Which leads to a vicious cycle of pain, spasm, tearing, more pain, more spasm, more tearing. And then you have an anal fissure. Ouch. No, seriously: ouch! Grab the walls, yell and cry ouch.

Most fissures heal, one way or another, without surgery. Hot soaks, stool softeners, various ointments or suppositories, injections. But some resist all that, leaving that patient asking for cure or death, whichever can be accomplished the quickest. Such patients, I treated as an emergency, imploring the surgery center to find a spot in a hurry (I had one of the three or four best centers on the planet one floor below my office. I say three or four because I accept the possibility that others could be as good. But, really, I doubt it.)

The operation is totally simple (lateral sphincterotomy). The idea is to break that cycle of spasm; so you make a cut in the muscle, off to the side -- forced relaxation. Applying a little pull while doing it, you can feel it release, like a rubber band. (There are two sphincter muscles there: cutting the most superficial, and smaller one rarely leads to control issues.) You can also just stretch the muscle, without cutting it. Personally, I don't think it's as effective. That release is like a bugle call: ta da. In rides the rescuer, swooping up the patient into heroic arms and riding off in glory. "Oh my god, doc," says the patient when it's over. "I love you. You're my hero. My kingdom, my gold: it's all yours." "Happy to help," I say, humbly, while walking off with at least some of the gold.

IMPORTANT NOTE (added 12/09): I'm beginning to think this post must be linked to some sort of forum on anal problems, because I'm getting a steady diet of questions lately. I'm truly delighted that my blog continues to be a source of information for people; that was, most certainly, one of my goals. On the other hand, I hope it's evident from my posts in general, and from my responses here in particular, that I'm not comfortable making specific diagnoses or treatment recommendations. I'd like to, really. But the problem is there's no way I can ever know for sure what's going on, and the last thing I want to do is substitute for or supersede in any way the input of a physician actually able to assess the situation directly. My aim has been to provide general information. Because my recommendations, absent direct involvement, might be wrong, and because it might delay a person from contacting their own doctor, I simply don't feel right about doing it.

SECOND IMPORTANT NOTE (added 10/10): I'm closing comments in this thread. The last four or five comments will demonstrate why. It ended badly, and I'm sorry for that. I must be getting crotchety in my old age. On the other hand, I'm pretty confident that any information I'd have to pass on to future commenters is already available in the original post and in my many, many responses to questions I've received. And the point of the first update still applies.

THIRD IMPORTANT NOTE (added 4/13): I recently did a series of interviews for a website. Below is what I had to say, in the brief time allotted, about anal fissures:

332 comments:

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Anonymous said...

Sid,
I am Indian. Vegetarian. Eat lot of fruits & vegetables. Drink more than a litre of water daily. 73..years old. Suffering from painful, sometimes bleeding fi 3ssures for 55 years.External ointments don't help. It generally disappears on its own after seven or eight months> I put up with it. After 12 years of no fissure, am having it again with occasional bleeding since last May.I walk for 20 minutes in the morning and 60 minutes in the evening.My friends say walking aggravates fissures. Is that so? any other suggestion of a general nature? I am a writer. Sit before my computer for 8 to 10 hours daily.Is that also an aggravating factor? You are an angel. god bless.

Sid Schwab said...

anonymous: In my opinion (which is not definitive) walking and sitting are issues more for hemorrhoids than fissures. As to your diet and fluid: the end-point as far as fissures are concerned is that you have well-formed, bulky, but moist and not hard bowel movements.

Having recurrence after so long raises the question of diagnosis: in other words, it's important to be sure that it's another fissure and not something else, especially if there was no triggering event such as a period of constipation and hard stools. So I'd suggest a checkup with your doctor.

Anonymous said...

A doctor, who examined it, said that I have a fissure and that the acute pain is due to severe spasm of the sphinter( I hope I have spelt it correctly) muscle.He suggested liberal application of proctosydl or similat ointment four or five times a day. No benefit.It bleeds four or five times a month.Pain and burning sensation after motion. Thanka

Anonymous said...

A doctor, who examined it, said that I have a fissure and that the acute pain is due to severe spasm of the sphinter( I hope I have spelt it correctly) muscle.He suggested liberal application of proctosydl or similat ointment four or five times a day. No benefit.It bleeds four or five times a month.Pain and burning sensation after motion. Thanka

z-bach said...

Sid,

Thank you very much for blogging on this topic. I have been researching the internet for info. on anal fissures for many days and your site has been very informative. I hate to say that misery loves company but it is comforting knowing others out there are going through this HORRIFIC pain.

I was diagnosed with a fissure 2 years ago. Went to the doc and he gave me some suppositories, cream etc. They have come and gone over the last couple of years up until this last week. I have been suffering terribly for almost a week now (way longer than normal). About an hour after a bowel movement I would rate the pain on a scale of 1-10 pushing a 9. I have broken my colar bone, ribs, leg etc. and it does not even come close to the pain this is causing me. I think I would rather cut my own finger off as opposed to going through this crap.

I saw a a surgeon a couple of days ago and he jamed his finger in my tight (frightened) anus and said I have a mild case of hemroids and a small fissure and it was not at the point where I needed surgery. I though to myself a SMALL FISSURE? Are you kidding me? I do not even want to fathom what a big fissure feels like. He prescribed me hydrocortizone suppositories and told me to take sitz baths etc. (I have done all this crap before) I have been taking the nifedipine cream for the last month as well from a previous visit from the doctor. After I went #2 today about an hour or so later I had such bad spasm's and pain it was unreal. It lasted for a solid 3 hours non-stop. (I think I made the mistake of using a suppository AFTER I had my bowel movement(although I put one in the night before) because I not only had the spasms but I had terrible burning to go along with it. I am almost at the end of my rope. This pain is ruining my life.

I have been a pretty healthy eater (lots of fiber fruits/ vegies), drink plenty of water, and I have been taking metamucil for almost 10 years. I am beginning to wonder if the bulking up from the fiber is actually CAUSING my problem. I have never really been constipated but sometimes I do strain a little and that is when it seems to cause the fissure. Also, I have been keeping a diary of what I eat and I noticed a day or two before my last bad fissure episode I ate a lot of popcorn.

My surgeon did not think that popcorn could have caused it but I am beginning to wonder. Combine bulky stools with hard undigestable nuts or seeds and this might be my culprit.

Have you ever heard of nuts/seed causing fissures?


PS... (hells bells anonymous post made me laugh so hard I almost cried because I can relate to a tee.) First time I have laughed in a while.

Thanks,

Z-bach

z-bach said...

Oh, I forgot to add I am absolutely HORRIFIED about eating anything because I do not want to go #2. I am basically trying to go on a liquid diet along with stool softeners. After todays episode I called him back and he prescribed me lidocaine as well as Darvocet for the pain. I am going to start praying a lot too.

Thanks,

Z-bach

Sid Schwab said...

z-bach: I don't think specific foods are generally the cause of fissures; it's the hardness, more than the content (although spicy foods can be painful on the way out.)

I don't think a digital exam is always able to quantify a fissure; in fact, when I'm sure that's what it is, sometimes I've not even tried; rather, I've done the definitive exam and Rx at the same time, under anesthesia.

The one part of your story that's perhaps unusual is the one hour interval between the BM and the pain, if I understand your correctly. Usually there's severe pain during the BM, which can increase over the next period of time. So it could be something else, such as levator ani syndrome.

I can't judge your surgeon from here, but it might be helpful to get another opinion, possibly from a colorectal surgeon.

z-bach said...

Sid,

Thanks for your quick response. I actually did see a Surgeon specializing in colon.

How can they tell if it is a fissure by just feeling? He was asking me is it here, is it here, then moving his finger around. It was kind of hard for me to tell because everything hurt all over.

Today, it hurt when I went number 2 but the spasms REALLY seemed to kick in about an hour later and lasted for 3 hours.

The other thing that is confusing to me is my stools look soft to me. They do not look very hard although they are bulky.

Thanks, I really appreciate your responses.

Z-bach

z-bach said...

Oh, and he said in a few weeks he wanted to go up a little farther with a probe or camera thing.

Sid Schwab said...

I don't think you can tell with certainty by finger exam.

I can't add much more; the doc you have is better able to answer specifics; since he's a colorectal guy, I'd assume he knows what he's doing.

Anonymous said...

I had a chronic anal fissure for over 11 mths after child birth. I even had to go to the ER after one bad episode. I was prescribed Rectogesic which didn't help. I ended up losing alot of weight as I didn't want to eat. I then got sick with chicken pox which later caused meningoencephalytis. The only good thing about getting this horrible illness was that it caused my anal passage to bascially loose its muscle tone, which meant that when I passed a BM (which I had no control over) there was no spasm after the BM which meant for the first time in 12 mths the fissure healed after 3 weeks. Now 12 months on, I only have very mild cases of reoccuring fissures (which are a breeze compared to the first 12 months). So basically the only reason my fissure healed was due to the relaxing of my anal passage when I was sick. The upside of the downside....

Anonymous said...

Hi Sid,

I had a lateral internal anal sphincterotomy 4 yrs. ago. It took away some of the extremely intense pain of the anal fissure and fissure was able to heal...however, I am still in significant pain. The area where incision was made is very sore, and I have a burning, stinging sensation often, esp. after a bowel movement. It sometimes feels like there's a thorn in there. I have been to many docs, had MRI, colonoscopy, etc. and no one can find anything wrong other than proctitis. Was treated with a course of Meslamine, but that didn't help. Am wondering about nerve damage that could have happened during surgery. Any thoughts? I am a 42 yr. old female and feel like life is passing me by as I suffer through each day and my 2 children wonder why mom always feels bad. Many thanks in advance for any feedback.

Sid Schwab said...

I doubt I can be of much help if so many others haven't. The one thing that occurs to me is the possibility of a neuroma, which is like a glob of scar tissue that can form on a nerve from injury, surgical or otherwise. Assuming there's no more fissure, and if your symptoms occur when the scar from the surgery is manipulated, it's a possibility. The problem is that the "treatment" would mean opening the scar and excising the scar tissue in it. It's iffy, since more scar will form. I've done it a couple of times in scars. Never for a LIS scar, because I've never seen the situation where I'd suspect it.

I assume that among the docs you've seen is a colorectal surgical specialist. If not, you should see one. If so, you could consider finding one at a referral type hospital, ie a university or big city referral center.

EndoNurse said...

Dr. Schwab,
I have read your old posts and Thank-You for having this site! I have learned a lot about fissures.
I work in endoscopy, am female, and in my 30's and I never knew exactly how much they hurt until I had my own, I had it for 1 1/2 years and just thought I had a difficult hemorrhoid. It amazes me now thinking about how when I felt unsure if I would pass out or vomit while I was on the toilet, that I thought that was normal.
Thankfully I had a doctor prescribe me Lidocaine HCL 3% with Hydrocortisone Acetate 3% cream back a year ago for my self diagnosed "bad hemorrhoid". He saved me from whimpering at the thought of going. I had also read on line about using your diaphragm by breathing to push the stool (as opposed to bearing down) and this helped a lot - and I know this might sound bizarre, but I also used Lamaze breathing when the pain was intense and this allowed me to relax the muscles down there easier and focus on breathing so I was able to block out the pain.

I saw a general surgeon 2 weeks ago who took one look and preformed a brief digital exam and said I had a fissure. I have surgery planned for a week from today and, of course, I am very concerned about incontinence, but the thought of going through my life in severe pain at times (mine was never constant) has motivated me to do something. The post surgery pain according to the doctor is bearable, I heard I should expect to take about 3-4 days off post surgery and then be okay to return to work.
I have five questions please:
1. What are the chances of a fissure healing by itself after being around for 1 1/2 years now that I know what it is? And if it did heal, would the anal papillae(which I thought was a thrombosed hemorrhoid) go away?
2. Is there anything that you recommend to do post surgery to increase the healing so that it is easier to heal properly? IE heating pads, special creams, fish oil. I figured usual suspects of soft diet with colace for a bit.
3. Is this length of discomfort accurate? It sounded fine to me, I really have a good threshold for pain, so I didn't expect to be down this long.
4. Do thongs make this condition worse? Do they put too much pressure on the anal area?
5. It is okay to have a hemorrhoid taken care of at the same time as doing the lateral partial internal sphincterotomy and removing the anal papillae?


Thank-you again, I have really enjoyed reading your site and I value your expertise.

EndoNurse said...

And just to complete the history - I have had a colonoscopy about 2 years ago and every is normal (except a hemorrhoid) because my brother had a colon mass.
And I thought of one more question too.
6. Do you think a general surgeon who your GI doctor recommends and other a trusted anesthesia doctor recommends is a safe bet, or do you think going to a specialist is a wiser choice?

Sid Schwab said...

1. What are the chances of a fissure healing by itself after being around for 1 1/2 years now that I know what it is? And if it did heal, would the anal papillae(which I thought was a thrombosed hemorrhoid) go away?

By itself, not too likely. With alternatives to surgery, such as nifedipine or botox? Could happen. Don't know about the papilla, but they're generally not a problem, per se.

2. Is there anything that you recommend to do post surgery to increase the healing so that it is easier to heal properly? IE heating pads, special creams, fish oil. I figured usual suspects of soft diet with colace for a bit.

I usually recommended taking mineral oil to lubricate the stools during healing.

3. Is this length of discomfort accurate? It sounded fine to me, I really have a good threshold for pain, so I didn't expect to be down this long.

It varies. I'd go with what your surgeon tells you, based on what he does and his experience.

4. Do thongs make this condition worse? Do they put too much pressure on the anal area?

I have no info on that.

5. It is okay to have a hemorrhoid taken care of at the same time as doing the lateral partial internal sphincterotomy and removing the anal papillae?

Depends on the extent of the hemorrhoids. Best info would be from your surgeon.

6. Do you think a general surgeon who your GI doctor recommends and other a trusted anesthesia doctor recommends is a safe bet, or do you think going to a specialist is a wiser choice?

I'm a general surgeon, and did the operation frequently. I think people recommended me to others. I guess it depends on particulars which I have no way of judging. When people ask me how to choose a surgeon, my first advice is to trust the recommendation of your primary doctor, assuming you have one and have reason to trust him/her.

Anonymous said...

I am hoping you can shed some light on my recovery issue after undergoing LS surgery for an anal fissure and removal of internal hemorrhoids. My surgery was 25 days ago and the area where the incision was made for the LS is still amazingly tender, but worse than that is the deep, dull pain within the muscle on my left side. I just saw my doctor for the 3 week checkup and he said it's normal for me to still have pain in the muscle. I have occasional sharp, knife-like pains there (which he referred to as normal post-operative spasms) but those are becoming less frequent and less intense while the aching pain within is not. It is amazingly difficult to get comfortable sitting as the pain doesn't lessen much by "sitting on the other cheek." Standing is better but the numb-like dull pain within the muscle (and it sometimes feels as if it extends dully down the length of my leg) doesn't let up much then either. The pain is tolerable but frustrating and leads me to believe something is not quite right, especially given a lack of seeing anyone else describe this post-operative pain. My doctor said one more week (meaning a full month after the surgery and I should be in the home stretch) and asked to see me a month from now. My sister had this surgery about 10 years ago and felt fine after a week. Should I be concerned or can you shed some light on the possible cause(s) for this chronic pain? Thank you!

Sid Schwab said...

Since you've just seen your surgeon, I'd have to assume that there's nothing obvious going on. I don't think there'd be harm in trying warm soaks to try to relax the muscle: ie, nice warm baths. If there's no fever and no purulent (pus) drainage, I'd think that time will solve it. But if things get worse, or if you don't notice progress week to week, see your surgeon sooner than a month.

EndoNurse said...

Hello Dr. Sid,

I had the lateral sphincterotomy 6 days ago. I am doing really well. I am 100% continent, taking baths often, taking Ibuprofen 2-3 times a day. I went back to work on Friday (had the surgery Monday). My only complaint (which is minor) is a constant pressure sensation and discomfort with trace blood on BM's, but I know it has only been 6 days.
I was doing great until a stitch got a little stuck in my undies (maybe it was ready?), all I know is that it came out and I felt a little pressure first. It didn't hurt, just pinched a bit. I didn't have increase in pain or bleeding. I called the doctor (over the weekend) and the on call doctor was in surgery so I spoke to nurse and told him the above.
Well, I try to check out the appearance daily to watch for S/S of infection and have noticed a hole now that I didn't see before - I am guessing where they cut off the tag and closed it with a stitch. This is not a suture hole, this is a hole next to my rectum, about the size of a small pea (think crater with the bottom being larger than the top - the top part more hidden).
I have an appointment with my doctor to follow up on Thursday, tonight is Sunday.
What do you think it is? Do you think that I should follow up sooner with another doctor in the practice or should I wait for him, I was planning on calling tomorrow to try to get in Tuesday (he is only at that location 2x a week).
Lastly, do you think they will stitch that area closed in the office - which is okay with me, or do you think they will leave it open (and would that be okay)? I am just worried, I know it is late, but I just wanted a speedy recovery and now I am concerned.

Thank-you again!

Sid Schwab said...

Endonurse: of course I can't really diagnose what's going on without seeing it, but since you're doing fine otherwise, it sounds okay. But it never hurts to let the doctor's office know when things change.

It's highly unlikely that there'd be an attempt to suture it back up, no matter what's going on. Most things heal fine in that area with time, and basic attention to cleanliness: shower or bathe the area, and allow it to close secondarily.

cat said...

Hi,

I am so glad I found this blog! There is so much information.

I have a question about LIS surgery recovery. I had it about a week and a half ago. The first week went great! Bowel movements were easy and there was virtually no pain. Just some blood which was lessening everyday.

I got to the point of no pain or blood (I've been keeping my stools very soft). But on day 8 I had a slightly harder stool and I could feel one of my fissures reopen. (I had two - one of them feels healed).

It's been a few days since that happened and it's been touch and with getting it to close up.

My question - is there any chance that it will still heal from the surgery? Or have I lost my window of opportunity. (I feel that the incision site has healed well already)

Anonymous said...

God sent me to your blog..for this I am sure! After 5 months of dealing with the most pain I have ever experienced..the doctor told me yesterday that I have an anal fissure. Next week he is doing a look-see to make sure nothing else is going on. In the meantime I am using the lido 2% Mifed 0.03% along with stool softner and a fiber supplement. You have mentioned mineral oil..do you think I should use that now as well? How do you get it into your system?? I want to be the most aggressive I can to try and not have to think about surgery. Thank you so much for reading and your possible response.

Sid Schwab said...

cat: you're still very early in the healing process, and there's no reason to assume, at this point, that you're off the track to recovery.

Sid Schwab said...

Anonymous: most pharmacies will have mineral oil for oral consumption. You take a couple of tablespoons twice a day, more or less depending on results. It's just to lubricate the stools to make them pass more easily. If your stools are already at that point, then the mineral oil won't add anything.

Anonymous said...

I am writing to you from the UK.
my wife was diagnosed with an Anal Fissure about a year ago. Last December after no luck with creams etc. she went to see a colorectal consultant surgeon who recommended botox injections. She had this operation and now, 4 months later she is still in severe pain. The Consultant has examined her twice(once under general anaesthetic) and says that the fissure is completely healed and that he can find no further problem. My wife however is still suffering- she says the feelig is like having a boil up her rectum and she cannot sit for longer than an hour. The Surgeon we have seen is one of the top men in this field in the UK! yet he has no idea what it can be. Any suggestions!?

Sid Schwab said...

Sadly, if a leading UK expert can't figure it out whilst (UK usage) having the benefit of direct exam, I'm sure I couldn't from over here.

The characteristic pain of fissure is severe pain during and for a while after a bowel movement. If her pain is mainly while (US usage) sitting, it might not be a fissure. Absent fevers, it's not likely an abscess.

There are some unusual syndromes related to pain in the coccygeus or other rectal muscle, digital massage of which can be useful. I suppose, absent any explanations, I might order a pelvic CT scan. Or perhaps a consultation with another colorectal specialist, just to get fresh eyes, would be useful.

Anonymous said...

Hello,

I was wondering if you have heard anything about wheatgrass cream for the treatment of fissures. I read about it online - seems like it is kind of a "too good to be true" type of thing.

Do you know of any fissures actually healing through this?

Also wondering if neosporin would be a helpful at all.

Thanks!

Sid Schwab said...

I have no info about wheatgrass, but I have healthy skepticism about such "cures." Neosporin would have little if any effect: the problem with healing has not to do with infection.

Anonymous said...

Dr. Schwab, THANK YOU SO MUCH for this blog. It's one thing to discuss my fissure problems with other sufferers, but it's actually immeasurably more comforting to be able to participate in a conversation that's being mediated by a doctor. You have helped to save my sanity a little bit today.

My question: can you comment on the effectiveness of Tramadol for pain control associated with my fissure(s)? I spent about about two hours writhing and crying in pain this afternoon (giving birth to my son 8 months ago was arguably less painful) and my doctor prescribed that for me. I was worried about Oxycodone (I've never used a narcotic like that before), so he gave me an alternative. Any thoughts?

LE

Anonymous said...

Sorry - LE here again. I forgot to mention that I read up on the side effects of both of those drugs, and constipation is one of them. I'm terrified of this possibility, but I doubt I will be able to withstand another bout of pain like that without the help of a serious pain killer (XS Tylenol doesn't help at all, and Ibuprofen hurts my stomach). Will my regular routine of hydration and Benefiber ward off that side effect adequately?

Thank you so much,

LE

Sid Schwab said...

LE: it's hard to predict a given person's response to a particular analgesic. Tramazol is pretty effective for most people; constipation can be a problem, but probably a little less than with narcotics. In the short run, while trying to heal a fissure, I often recommend taking mineral oil, in addition to whatever bulk agent a person is taking: a tablespoon or two twice a day. That can counteract the constipating effects, and help to lubricate the stool for easier passage over the fissure. Any pharmacy would have mineral oil for oral consumption.

Aeraxeur said...

Hello, I am a 37 year old male. Ive been experiencing symptoms of anal fissure for about a month. What happens is, Ill have a bowel movement, and it will hurt slightly. Then, about 1 hour afterwards, an extreme, stabbing, sharp pain will develop in my anus that will last until i manage to fall asleep, and then im fine the next morning until the next BM. This is some of the most horrible pain Ive ever felt. Aspirin, Motrin, Tylenol, completely ineffective. Also, preparation h, cortizone, rtonolane, benzocaine, lidocaine, prilocaine, desoxometasone all worthless for the extreme pain. Even oxycodone hasnt helped. The only home-treatments that have reduced my pain are: cleaning the anus with water after BM, applying neosporin with pain relief afterwards. Is this because bacteria affecting the fissure contributes to the pain? Also, ive been taking shots of patron silver tequila after each BM which dulls the pain. I guess I will have to see my dr.

Sid Schwab said...

Your conclusion is correct: you should see your doctor. It sounds like a fissure, all right, but it can't be diagnosed or treated from afar.

Anonymous said...

I have had a anal fissure for 3 months and triedn everything and nothing worked. I am to the point where death is looking better right now. I have LIS surgery scheudled for thursday....any words of wisdom to get me through the worries?

Sid Schwab said...

Only that the odds are that you'll be very happy you had the surgery.

Anonymous said...

I have had an AF for about 11 months, for the last 3-4 months I have had no symtoms or pain. But upon investigation by my GP the fissure is still there. How is this possible? I thought the pain caused the sphincter to tighten hence limiting blood flow hence limiting healing ability. If this is not the case why will my AF not Heal??!!??!?! UGGGG!
(the reason it is still a concern is i want another child and i am worried pregnancy will agravate a cronic AF)

Anonymous said...

I have had an AF for about 11 months, for the last 3-4 months I have had no symtoms or pain. But upon investigation by my GP the fissure is still there. How is this possible? I thought the pain caused the sphincter to tighten hence limiting blood flow hence limiting healing ability. If this is not the case why will my AF not Heal??!!??!?! UGGGG!
(the reason it is still a concern is i want another child and i am worried pregnancy will agravate a cronic AF)

Sid Schwab said...

Being unable to see it, I really can't comment meaningfully. I suppose it's possible it's effectively healed over the muscle but there remains some granulation tissue on the surface. However, since it's unusual to have an open fissure and no symptoms, I'd think of having it looked at by a surgeon, to confirm the diagnosis and rule out any other explanation.

Anonymous said...

I started using Recogesic for my cronic AF. Would this in anyway aggrivate my old external hemorrhoids? As they are now extremely sore and uncomfortable. I cant see any other change or reason for this flare up except for the cream.

Sid Schwab said...

I don't know of a reason why rectogesic would affect external hemorrhoids, although with any ointment I suppose contact dermatitis or other form of allergy is possible. Any change in the area is best evaluated by someone who can look at it directly.

Antonios said...

I think I have read all the comments on this blog, but there are some issues that haven't been mentioned.
I would like Sid and the other commenters to comment on their experiences on the following:

1. I had hemos for several years, but I didn't put much importance to them, probably, none, because they bothered occassionaly, with some hard constipation, that lasted a few days or even only a few hours. Nothing serious I thought. Never looked up any info on hemos. Had two colonoscopy because of other issues: probably IBS, but I was relatively healthy. I don't smoke, no alcohol, no drugs, and try to eat and have a healthy life style. I think most people do the same: forget your occassional hemos when there are other important things to do.

2) I am a 56 year old male that had his first encounter with the seriousness of hemos three months ago. I had a very hard constipation. When the thing was coming out I felt like a knive cutting through in one section of my anus. Through out a lot of bright red blood. More than other occassions. Since I had these but on a lesser degree on other occassions I didn't bother much. Until the burning, pain started. Tried the ussual OTC creams and treatments. No relieve. Went to a Gastro. Gave praxamaine with hydrocortine for out and inside application. I think that the tube tip did some hurting. He said that if in three weeks I didn't get better he would refer me to a surgeon for evaluation. Things kept the same or became worse.

3) I went to an emergency room since the burning and the pain were great. The two physicians saw my condition and made me stay until a surgeon could evaluate me. The next day the hospital's general surgeon evaluated me and said that I had thrombotic hemos and that I needed immediate surgery. I called my Gastro for his opinion, but it was a Monday holiday, and couldn't be reached. My family said that if I waited it could turn worse, so I signed for the surgery, which was done the next day. And on the following day I was released with a successful surgery, surgeons opinion. I felt it was, too. I wasn't given any instructions on how to care for my hemos after surgery.

This is quite an extense comment but I think that it could be helpful for others and with the comments to it, for me.

I greatly appreciate your opportunity for this blog. Other blogs mostly have sufferers commenting about their experiences but with no specialist moderating them.

Thank you.

Antonios

Antonios said...

I am antonios, and this comment is a continued part of my last comment, it was to extensive to fit in one comment, but important issues are included here that are not mentioned in other people's comments:

4) At home I spent two weeks mostly in bed, I wanted to recover the fastest possible since on the third week I had to start work in a new job. I was just laid off by the state's government massive no-funds employee firing. Luckily, I could do that. Apparently, all was well. Although I still felt some pain after BM, but I thought all this was part of the healing process. Since I wasn't shy I told everybody about my hemo surgery, and discovered almost everybody has had hemos during their lives, but don't talk about it. Since the surgeon didn't give me instructions I followed these other people's advice almost to the letter.

5) I went to my new job with a donut, because it required extensive sitting. Following quitely my hemo colleagues recovery instructions. I went to the surgeons followup appointment he looked at my anus and said that it was perfectly cured, stitchs were self disolving.

6) Since the after BM burning and pain continued even following healing procedures with home remedies and otc treatments, I spent weekends at bed trying to help recover. I went to my Gastro again and he, too, found everything fine. During this time having nothing to do and having a laptop with wireless internet I started looking for hemo info. I was kind of desesperate. MY real hemo training and education started. WOW. All the things that I have learned. I guess other hemo sufferers go through the same process, start online seeking when they realize that what is available locally doesn't heal them.

6) With the web help I learned that their are thousands of people suffering in silence and even outloud because of hemos. Since probably the people that participate in blogs are the non-healing sufferers it gives the impression that having hemos burning and pain is a life time event. I hope that mine will be the one with a life time cure.
I hope that millions of past hemo sufferers have been cured for good and that's why you don't hear of them in the blogs. They don't need them.

7) I did all kind of Google searches: hemorrhoids, natural cures, etc. Since the traditional medicine didn't seem to work, looked up naturals. but there is a diversity of treatments. Found a book. written by an ex-sufferer, did a Google search for it: adding scam, fraud, rip off, and other variables, and nothing negative appeared. but it appears that everybody is selling the book. Couldn't try the herbs, because did a google search and I found that some "natural herb" processors adulterate, contaminate, and even add western drugs to the ingredients without mentioning it in the label. So even with naturals you have to investigate if the manufacturer is honest and doesn't kill you.
These products have a 100% refund, if it damages wiil the refund be worth it?

Continued on next comment...

Thank you.

Antonios

Antonios said...

Antonios again with additional issues now medical-legal in some part:

8) With all this searches I learned that my non-healing aspect of my hemos could be an anal fissure. My symptoms lead me to believe that. With this info I did a second visit to the surgeon. He said he saw things fine, but refer me to a Gastro. I went to my Gastro, talk about my findings and he refer me to a colon-rectal specialist or proctologist. I have had to take sich leaves on my new job because of the pain specially when sitting and driving.

9) I called a colorectal specialist that operated a physician friend of mine that had a worst condition than mine, and had him at his job in a month with nitrate cauterizations every week. The CRS told me that that was normal in general surgeons that were not experienced with hemo treatments: to work on the hemos and forget the fissures. That if I had gone to him first he would had worked on both of my problems at the same time and that by this time I had been cured. BUT, and this is a BIG BUT....

10) That surgeons DON'T see surgeries done by other surgeons up to A YEAR after the process have been done. This because they fear malpractice lawsuits. Even if you suggest a legal form indicating that you won't sue. He said that he had gone through the embarrassing experince and don't want to repeat it. Since my process is only two months, I did have to wait ten more months for him to see me. Called a proctologist and told me the same thing about not accepting seeing other surgeons work.
Any suggestions?
I live in Puerto Rico a Commonwealth of the USA and apply the same federal laws as any other state of the Union.

11) Apparently, I added another misfurtune to my suffering. Apparently, I develope and have a tender spot just outside the anal fissure, and during driving it hurt quitely, but in three occassions I had to dive quite a distance apparently hurting that spot. Now I have it in addition to my fissure a laceration, abbrassion or inner butt skin hurt. I don't know how to call it.

12) Most of my pain and burning come after BM. Even with ease of the thing coming out. No constipation. It seems as though the faeces has some kind of chemical that hurts the anal fissure. If this acidity or chemical could be neutralized the burning and pain could probably be reduced greatly or even eliminated and probably the healing process could be faster, even instant. Any suggestions?

No BM no pain: is their any thing in process that can cover the AF so that when faeces pass they don't touch the fissure?

Hopefully, there is a cure for me and other similar sufferers.

Ultroids anyone or any other similar non invasive treatments?

Thank you.

Antonios

Antonios said...

I have seen suggestions on other sites about Venapro, Fargelin and Heal Fissures.

Has anyone tried these "natural" remedies?

I have read that Venapro has pranax ginseng that could be a toxic, that some Fargelin manufacturers add arsenic to it, a poison, and I couldn't find comments on "Heal Fissures" only those on the site that sells it.

Of course product testimonials talk about the miracles of each product, but it they are true, could be the "placebo" effect?

That is, if you believe that something is going to cure you, it does, even if it is not a medicine. This has been done with sugar pills, and water with coloring. Of course, this doesn't work for most people.

And that's how you know if the product is good or not: if most people cure it is good.

If it doesn't, the company won't tell. So you have to rely on sites like this one, where you expect unbiased opinions.

Sincerely,

Antonios

Sid Schwab said...

Antonios: since this post is nearly three years old, I don't think you'll get much feedback from prior commenters. I do get new comments here once in a while.

Reading your comments, I thought from the beginning that it wasn't just hemorrhoids, but a fissure. It's a typical story.

You might be able to find another CRS who'd care for you now. I've certainly never heard the "one year" rule.

I know of nothing to cover the fissure. Using mineral oil (a table spoon or two, by mouth, a couple of times a day, using the pharmaceutical kind) can make the feces pass more easily and less painfully. It's important to have enough fiber of one sort or another in your diet to keep your stools from being hard.

Botox injections, topical nitroglycerin, nifedipine are non-surgical options for treatment of fissures.

EndoNurse said...

Hi Sid,

I had my fissure repair with the tag removal in March 2010, I wrote to you about your opinion and then post surgery about a busted stitch. I wanted to let you know that the surgery worked.
I am pain free and wanted to say, thank-you for your advice.

The only complication (but I am hesitant to call it that, I don't know if it is par for the course) is my site did stop healing and it was leaking a little serous fluid so I knew something was not quite right (it was kinda lite yellow/green with no odor or pus and maybe 2 pea size in diameter worth a day would be on a little tucks pad). I made a follow up appointment last week and the Dr. used a sliver nitrate stick on the granulated area to help restart (speed up) the healing process.
Just curious, (1.) how common is this and from this point forward, (2.) anything you can think of to make this area just finish up?

The leaky fluid kinda itches and once again, I am guessing it is normal to feel itchy when things are healing (at one point, it was itching so much it would wake me up and night so I used pin worm medicine - just in case). (3.) I found that witch hazel pads make the itching go away, why is that?

Thank-you. What you provide is peace of mind to many people. You listen and you understand. Your service that you do is very generous and very,very kind. You are a voice of knowledge and advice that comes when many people are scared, in pain, and embarrassed. Thank-you for your compassion to others.

Sid Schwab said...

EndoNurse: thanks for your kind words. They are appreciated.

I'd probably have tried silver nitrate, too, if I thought it was an excess buildup of granulation tissue, which can happen in any open wound. It's not, per se, anything to worry about, assuming that's what it is. When you think about it, the area has pretty much everything wrong with it as a place for perfect healing. It's amazing that it DOES heal, really.

Don't know anything about witch hazel, but if it helps I doubt there's anything wrong with using it. Sounds like it's a matter of time, keeping the stools easy to pass, and, if it's taking longer than you expect, to have it checked again.

Antonios said...

Antonios again:
I think that from driving with somewhat my butts squeezed or with my anal fissure pressed against the butts walls I have developed a lump or skin laceration just there next to the anus, it hurts alot. Although I am using the donut seat.

During BM I don't feel pain or burning, its after the BM. Stools are soft. After BM I kind feel something liquid (like a breeze) that gets over the fissure or skin laceration and there's when the burning sentation starts.

Today I had a warm slitz bath immediately after the BM and everything was quite well for an hour, until I put on lidocaine HCI 3% with Hydrocortisone acetate 2.5% gel. It burn real hot. I took another slitz bath to wash it off.

Apparently, my hemorrhoids are cured, the problems are the fissure and now this hurt skin that is painful burn.

1. Could I get asepsia (blood infection) from all these processes?

2. Could I apply nitrateglycerin on my own or it has to be done by a physician?

I am doing my best to get cure, but this is eternity!

Sincerely,
Antonios

Sid Schwab said...

Antonius: I think I've said all I can say without being able to see the lesion.

Anonymous said...

Dr Schwab, if you're suggested LIS but have a chronic fissure, is it wrong to assume it will come back? and if it does, what are the options? could it get to a point where you need constant surgery ?

Sid Schwab said...

Recurrence after surgery is possible, but pretty uncommon. I don't think anyone would recommend "constant surgery" if there were more than one recurrence, but looking into other causes would certainly be indicated.

Anonymous said...

thanks for your prompt comment.

i always have a feeling of constipation. i get a lot of fiber but not too much exercise anymore, i've been able to link the fact that i've had the same pains during my sports times compared to when i'm not playing.

i just dont want to go through surgery again (had it for something else)

does coffee help open up the internal sphincter muscle or external ?

Sid Schwab said...

I've seen it written that caffeine can relax the anal sphincter. I don't know how powerful the effect is in terms of healing a fissure, and I've never heard it recommended for that.

claire said...

Thanks for this post doctor! I can't believe how many people have found comfort in this post, I know I have!

I had LIS about 2 and a half months ago. I went in for my final check up with the doctor last week and she put this instrument up there, which I was scared would retear, but amazingly it did not! She said I am healed and that things looked great. (Again thanks for this post - it gave me courage to get the surgery!)

The problem is I feel like the fissure areas (I had two) seem weak to me. Like today when I had a BM a felt the one fissure site lightly pull/tear - but not enough to reopen it (felt more like a stretch - no blood or pain, just slight sting) this has happened maybe once or twice since I have been completely "recovered."

Just wondering - do fissures continue to heal stronger and stronger or do they heal as good as they can with in a few weeks. In other words - will my fissure sites ever be as strong as they used to be? (I got the fissures by having anal sex without enough lube)

Sid Schwab said...

claire: the healing process continues for many months, no matter the surgery. Meanwhile, it's important to keep your stools firm but easy to pass, which means plenty of fiber and hydration.

Anonymous said...

Dr. Sid about how long after the lateral internal sphincterotomy can I engage in anal sex?

Sid Schwab said...

When my gallbladder patients asked a related question, I used to advise that they wait until they get home...

In my opinion, the answer vis a vis anal sex and LIS is trickier: at minimum it seems to me it should wait until there's no pain, and should be done with plenty of lube.

Anonymous said...

I was diagnosed with Crohn's disease just three weeks ago after a colonoscopy. I was told that I also have an anal fissure. I have had past problems with hemmorhoids and minor anus discomfort. Three days after my colonoscopy my fissure became excruciating painful. I made an emergency visit to the doc and was introduced to nitroglycerin. The first application was soooooo relieving and for several days things proceeded to get better. I have now seemed to hit a wall and at times (i.e. post bowel movement) in a lot of discomfort. My doctor told me that it could be anywhere from 3 to 6 months for a complete heal. I am twenty three years old, i love to bowl, i love my job, and i love to relax with my friends. All of these things are being seriously affected from my pain. I am looking for someone who has been through this before to just give me some comfortable reassurance that it will get better.

L said...

Dr Schwab -- I had the surgery in 2001, and while the surgery was successful, I still get fissures quite often. Usually they heal over a couple weeks, but now I've had a bad one for 3 months. I haven't had anything like it since my last surgery, so I have an appointment with another surgeon in a few days. I have two questions for you. First, have you ever performed the surgery twice on the same patient? Is there a greater risk of incontinence or other problems the 2nd time around? And second, I'm wondering if my own bowel habits have contributed to this ongoing problem. In the years since the surgery, I have never allowed myself to relax while going to the bathroom. I always try to hold it back and ease it out as slowly as possible to avoid pain. I feel like if I relax, it will burst out and cause or aggravate a fissure. But in this constant struggle for control (which I never win!), I don't allow the muscle to relax and stretch, and over the years it has gotten increasingly small/tight. I realize you can't comment specifically on my condition, but does this make sense? I'm hoping the surgery will loosen things up down there (I remember feeling that way after the last time), and maybe if I change my habits and learn to relax, I can put this all behind me. Of course I will ask the surgeon these questions, but I'd appreciate your thoughts in the meantime. Thanks!

Sid Schwab said...

Those are good questions, and you should ask them of your surgeon. It depends a lot on what he/she thinks is going on. What you describe might be "stenosis," ie, narrowing of the opening. Before cutting again, one might consider stretching it under anesthesia (the "Lord" procedure.) Not being there, I cant say whether it's appropriate or not.

It's also really important to find a way to have bulky stools that are easy to pass; ie with firmness but enough moisture that they aren't hard. It doesn't sound like you're there. Something also discuss with the surgeon.

L said...

Thanks for the response. I think they did the stretching along with the last surgery. I'll ask the surgeon about that. As for stools, I can't tell you the last time I had a hard stool. I am a master at producing soft yet bulky stools. Yet they still kick my ass. So to speak. I just seem to tear easily and often. I blame the super small hole I'm trying to pass stuff through. Up until now, they've always healed back up. Then I'd have a few nice days or a week or so and I'd be tearing again. Ah, the good life. Wish me luck! Thanks again. I just found this blog the other day, but I've read through all the comments. I appreciate that you're still reading and responding to them after two years!

Response for L said...

Hi,

This is a response for L. I had to respond to this because I had the EXACT thought about relaxing on the toilet. I had a chronic fissure that I healed with creams, and stool softener, but I was always terrified it would tear again so I would try to ease out slowly, pushing more from my abdomen, but keeping my anus tight. I always felt an uncomfortable stretching feeling the entire time I was healed which was about 8 months before it tore again. I just never felt back to normal.

Inevitably, the fissure reopened so I decided to get the surgery. The healing process was fast, but I was still so scared of having it reopen I would tense up and feel this uncomfortable stretching feeling - like it was on the verge of breaking again when I would go.

I went in for my 2nd post op appointment about 2months after surgery and told the surgeon, and she said it was nothing to worry about. Then proceeded to put an instrument up there! I was thought it would rip my fissure open and I would have to start the recovery all over again! BUT it didn't! I was amazed, she took a look and said I was completely healed.

Since that day at the doctors office I have had more confidence just to relax and just go as usual. And everyday I felt less and less stretching/stinging, and after a few weeks, I feel almost completely back to normal! After years of dealing with a fissure and/or pain/stinging/stretching. it is amazing!

My advice to you, take deep breaths and try not to focus on your fear. I call it zen pooping :) Also, I found lubing up with some olive oil before and after a BM helped me to feel more confident about going.

Anyway, I hope that helps! I feel your pain! Hang in there.

L said...

Wow, thanks. That helps a lot. It's funny, because this is such a metaphor for my personality -- I'm a worrier, a bit of an obsesser, and I try hard to control things that are out of my control. I guess they don't call it anal retentive for nothing. But yeah, it sounds like you know exactly what I'm talking about here. I'm so ready for a little zen. I consult with the surgeon in a few hours, so I'm hoping for some resolution soon and a fresh start. Thanks for the encouragement. Thinking zen! :)

Bailey said...

Hello Sid, I had LIS done many years ago, and have had post-bowel fecal leakage associated with nearly every bm I've had since the surgery (and I have at least 3 bms/day.) Somehow I developed a keyhole deformity (which I'm told is very rare w/LIS) that seems to be the culprit of the leaking. I've been to many colo-rectal specialists and I've been told to follow many different diets. However, it doesn't seem to matter what I eat - because it's gonna leak! I often have to clean my rear up to 3 times after one bm. It's as though I never cleaned it when I went. I've read of a procedure for treating a keyhole deformity, called House Advancement Flap. I would really like to know what you know about this procedure and if you think it is a viable option for treating the deformity. Thank you for your time and knowledge.

Sid Schwab said...

Bailey: I have no personal experience with the technique and no basis for judging it. I'd venture that its usefulness would depend on your particular anatomy. If you can find someone who uses the technique and who thinks it could apply to your case, it would be worth considering, based on what that person would tell you and what results s/he thinks you'd have.

Anonymous said...

Sid,

As so many others have said, I cannot thank you enough for creating this thread and breathing a little humor into this painful topic. Your generosity of time and information are very appreciated!

Like so many who have found you, I have been diagnosed with a painful, life-altering fissure. I'm 8 months in. I've read though this entire thread, but would like to ask a simple question about the very first post you made. You referred to the satisfaction you received by performing the embarrassingly simple LIS procedure. However, in many of the replies, people are going to great lengths to avoid this surgery. My question is this: If it were you, and you had a "typical" fissure with the extreme pain so many report, but with knowledge you have about efficacy and LIS risks, how many alternative treatments would you try before scheduling an LIS? Would you exhaust every other option (nitro, nifedipine, botox etc) before considering surgery?

I am at the point of needing to make such a decision, as I desperately want my life back, but have not yet tried botox. Should I? I've been to a colo-rectal surgeon, and he's told me the likelihood of success with each, but has left the decision up to me. If it is a simple operation with little chance of complications, why should I continue to suffer?

(Related question...I am on nifedipine and have seen no effect in 3 days of use. How long should I give it with no perceived effect before declaring it ineffective?)

Finally, if LIS is the route I end up taking, in your opinion, would you have it done by an experienced general surgeon that is local, or would be worth traveling a couple of hours to a larger city with a colo-rectal surgeon with 750+ procedures under his belt? In other words, how simple is "embarrassingly simply?"

Many Thanks!
FG

Sid Schwab said...

FG: the odds of healing without surgery go down with time; eight months is a long time. On the other hand, three days is not enough time to conclude nifedipine isn't working. More like three to six weeks. So, it's a matter of misery/patience/optimism quotients.

Hard to answer your local surgeon vs specialist question. Many general surgeons are pretty experienced with the procedure, and if you know one and feel okay with that person, the odds are it'd be fine. On the other hand (I guess I like that phrase) since you've met with a colorectal specialist, if you liked the experience, and you don't know a local surgeon, maybe that's the way to go.

As a general surgeon, I wanted to feel I could do the operation I was proposing as well as anyone; I think I was honest about that. It was only certain very complex and not-frequently-done ones that I referred to tertiary centers. I did a wide variety of operations, including the routine ones and the very complex, and I believe my results were as good or better than those of surgeons in large referral centers. For what it's worth, LIS was not among those I referred.

Anonymous said...

Sid,

Thank you very much for your quick response!

Regarding the nifedipine, I understand that healing is likely to take several weeks if it works at all, but should it have any effect on the symptoms sooner? If it is to work, should some relaxation be evident from the very first dose?

Also, any thoughts about the exhaust all options/enough is enough tradeoff?

Thanks!
FG

pvk said...

Hi Dr. Sid,
I've had fissures for over three years. I've tried everything except surgery (including nitro, nifedipine, diltiazem and botox) and nothing has worked completely. My pain has decreased somewhat over time. I used to agonize for hours over every bowel movement. Now, I have pain, sometimes intense and sometimes mild, but for just a few minutes after a bowel movement, and then the pain goes away pretty much completely (with some occasional exceptional bad days) and it generally doesn't bother until the next bowel movement. It's been this way for at least six months now.
I know I have no more options other than surgery and I'm very tempted to go for it, as it's a drag to have pain with every BM. But the occasional scary stories about bad outcomes after LIS have me worried. So, considering the fact that the pain is short-lived and better than it used to be, should I wait? Do I have any chance of eventually getting completely better without the surgery?
Would you be advising surgery at this point if you were my dr.?
Please be honest with me!!!
Thanks,
pvk

Sid Schwab said...

pvk, the reason to have the surgery is to relieve the pain and get the fissure to heal. If you find your current situation tolerable and prefer it to having surgery and its (small) risk of leakage issues, then there's no reason to have the surgery.

Assuming your bowel movements are "ideal", meaning firm enough to stretch the sphincter some, but still with enough moisture that it's not too hard, then there's not much else you can do to expect healing after three years. I neither have a crystal ball nor the ability directly to assess your situation; but from what you've said it seems your options are to accept the current situation or have surgery. The choice is based on your preference only.

Anonymous said...

I have been dealing with an anal fissure for the past 2 months, and have found this blog to be very informative. Thank you for taking the time to address our concerns.

I have a question regarding stool softeners. I have been using nifedipine ointment for the past 4 weeks, however, during this time frame the only relief I experienced was over this past week once I began using a stool softener as well. I take 3-4 tablespoons of lactulose a day, and coupled with the ointment, my anal region feels much better.

However, I realize lactulose is not safe for prolonged use, as your bowels may become dependent on this stuff. I have been taking lactulose for 8 days, and am wondering if it is safe to continue taking it a while longer.

Also, are there any natural stool softeners beyond high water and fiber intake (such as specific foods, liquids, supplements, etc)?

Sid Schwab said...

Long term use of lactulose is less of a problem than with stimulants, like ex-lax, etc. I do think the best solution, if you can find it, is the right amount of fiber and liquid in your diet. Some people do best taking a fiber product like metamucil or fiber tablets. There are plenty of high-fiber cereals, too.

I don't think you need to worry about taking lactulose until the fissure is healed; once it is, some sort of fiber regimen might be better if you can work it out. But if lactulose is working I don't think it's a worry. On the other hand, I don't like to make specific recommendations for people I don't know. Best to discuss it with your doctor.

Anonymous said...

Thank you for prompt reply. I am viewing lactulose as a double edged sword.

On the 1 hand, taking it does reduce my pain by a notable amount. However, I don't want to be taking it for months, to the point where my BM's become dependent on it, and therefore experience another fissure from the resulting constipation.

On the other hand, if I stop taking it now while my fissure is not properly healed, I will be back where I started.

Hopefully the nifedipine/xylocaine ointment works. For the first 3 weeks I applied it only to the outside, without putting my finger deep in. I experienced next to no relief.

Over the past week however I have begun going inside my anus, using finger cots and I feel a notable difference. However, whether this improvement is because of the nifedipine ointment being deeper inside (and possibly closer to the fissure?) or from softer stools as a result of the lactulose, I am not sure.

Anonymous said...

Hi Sid, I see some of your posters here have some hesitation in regards to having the LIS procedure. From my experience w/the fecal leakage from LIS, which I've had for over a decade now, is to avoid it, avoid it and avoid it at all costs! It consumes most of my thoughts throughout each day. I often cry myself to sleep at night, and am becoming a heavy drinker. I've lost my wife over it, as my depression has worn her down. We've had sex probably less than once/yr in the past 10 yrs or so - and I'm only 41 now. I have not had children as a result, and am sure I never will at this point. Dating again isn't an option. What young woman wants to date a man w/crap leaking out of his ass every day?! The internal sphincter muscle is the barrier between stool and the outside world. Cutting that muscle is a very bad idea. There's a risk the surgeon will cut too much of it, like 75% or even 100% (which is what happened to me.) The length of the incision made in order to get to the muscle also affects the chance and degree of incontinence. My incision is 3-cm in length (the entire length of my rectal canal.) The resulting scar has effectively become a "gutter" for stool to slide on out! This post is to let people know that that "small" chance of incontinence seems "enormous" when it actually happens. And believe me, there's no way to correct the problem when it happens, other than "not" eating of course.

Sid Schwab said...

That describes the worst possible outcome, and I'm sorry to hear of it. I can't speculate on how the operation was carried out, but it's far from typical. When a result like yours happens -- which is exceedingly rare, enough that I never saw it -- it's devastating. I do think it's worth pursuing other treatments. It's not impossible to to find a solution.

Anonymous said...

Sid, yes I am aware that I've described the worst possible outcome. I posted it only because people need to know what "could" happen. My surgeon was an experienced colo-rectal surgeon who claimed to have done the procedure countless times during his career. He didn't even warn me that incontinence was a possible side effect. I actually was under the impression the muscle completely healed itself some time after surgery. Thanks for your link to solutions to fecal leakage related to sphincter damage. I've actually had the overlapping sphincteroplasty done, maybe 5 years ago. It did help some, but the problem still exists. The surgeon said there was a large space to repair, so I'm assuming the muscle isn't close to 100%. I've tried many different doctor-prescribed diets w/no luck. I've done biofeedback and muscle exercises, but my external sphincter muscle is "extremely" strong per the opinion of every surgeon I've seen. Secca is the only procedure I haven't tried, but have done extensive research on it. Even if my internal sphincter muscle was once again a complete circle w/adequate tone, I think the huge scar I have would still cause leakage. I feel I've exhausted every avenue available to me to correct my problem. At this point I'm mentally drained and have to find a way to live w/it - alone. Again, I'm posting so others might avoid my situation. I encourage anyone w/a fissure to do everything possible to avoid surgery. If surgery is necessary, I recommend insisting it be done as conservatively as possible.

A.F said...

What is the treatment length for nifedipine cream/ointment? Ive read many accounts of people using this cream/ointment to treat their fissure, but the length of time it was used differed.

Sid Schwab said...

AF: I don't really have a good answer. If it's working -- meaning there's notable lessening of pain -- it's reasonable to keep it up until there's healing. I guess the harder question is how long to give it until it's concluded it's not working. I think if there's no noticeable improvement after two or three weeks, there's not much reason to think there will be by continuing.

However, as usual, I have to say that given differences among patients and their fissures, it's best to get the advice from you doctor, the one who prescribed it.

A.F said...

I am starting to come to that conclusion as well, as I have experienced little relief. I will go a few days where it begins to feel better, only for the reset button to be pushed towards the end of the week and then I am back to square one.

My diet is fine, with a daily intake of 40-50 grams of fiber, and 12 cups of water.

From the studies I have found online, treatment length seems to range anywhere from 4 to 8 weeks, and the concentration ranged from 0.2% to 0.5% nifedipine. However, whether the fissures were acute or chronic was not clearly defined.

I assume my next option is botox. I imagine these shots are quite painful when administered...?

Anonymous said...

Hi,

Thanks for this post! Very helpful!

I had a question about a fissure getting infected. How do you know if it is? I have a fissure that is ::cross fingers:: healing. And at first sometimes after a bowel movement it would be itchy, but That is usually the case for me. But then one day it was really itchy and I couldn't help but scratch it, even tho I know it makes it worse. And for the last few days the area around my anus has been slightly red, which could just be irritated from scratching, but it seems to be getting back to it's normal color. But Im not sure if it is! It still itches but not nearly as much. And I'm not having any pain during or after bowel movements, in keep them very soft.

Is there a possibility it is infected? Or would I definitely know? Would I be experiencing more pain and see a weird discharge?

Thanks!

Sid Schwab said...

Itching is pretty common in healing wounds. If the redness is diminishing, the pain remains gone, and you don't have fever, it's unlikely there's infection.

By definition any open wound has lots of contamination and some discharge. Infection, in the sense of something serious, would imply bugs getting into tissues around the area, deep. There'd be swelling, pain, and fever in most cases. However, when you have concerns the only one who can actually diagnose and recommend is one who is able to examine it. Which doesn't include me.

Anonymous said...

Hi Sid, I recently posted on here I have a large scar from LIS. I was thinking of seeing a Plastic Surgeon to see if he/she would be interested in revising the scar somehow for "functional" purposes. If in my position, would you pursue something like this?

Sid Schwab said...

Not sure what you mean by "functional." If the problem is leakage, then I'd think an experienced colorectal surgeon would be a better option, although there may well be plastic surgeons who do reconstructions of the perineal area. If that's not the issue, then since I don't know in what way the scar is bothering you, I can't say. Generally, I'd be reluctant to mess with that area without a really good reason.

Anonymous said...

Hi Dr. Sid, (Part 1)

I'll just refer to myself as P.I.T.A. for purposes of standing out from the crowd of anonymous contributors. :) And I want to thank you profusely for this forum, your knowledgable and caring input, and your willingess to assist and/or relieve suffering with no financial remuneration. Simply amazing.

I'm scheduled for LIS and hemorroidectomy later this month. I'm scared spitless. I have had the current problem of fissures for about nine months and there are two fissures present with sentinal piles, one anteriorly and one posteriorly. Also, I have left over tissue on both sides of the anus from past hemorroids that my surgeon feels must be removed as they overlap. He thinks they will inhibit the healing process.

My questions are:

He states he will excise the superfluous tissue and then stitch each wound closed. I'm thinking big-time pain and wondering why he doesn't just cut and cauterize or band? I'm not questioning his skill. He is well established here and I've researched him online with favorable results. It's strictly a procedure I don't fully comprehend. Perhaps you would be so kind as to explain a little more? I don't want to make him feel I have no faith in his technique. (Afterall, I will be unconscious and he IS operating on my butthole. That's not someone you really want to irritate.) And I don't know enough about the technique to question it anyway. I'm just curious.

Secondly, both fissures are currently manageable without severe pain but I know this condition is only temporary. I have had them reopen too many times after a month or two of healing and manageability. Consequently, I'm not questioning my decision to have surgery. He tells me the surgery will bring me back to nearly open-fissure-type-pain for 1-3 weeks (from the hemorroid part of the surgery, not the LIS) but that fissure patients aren't shocked by the level of pain, as are hemorroid patients who have rarely experienced this level of screaming-into-a-pillow-for-four-hours type torture. Has this level of post-surgery pain been what you've seen as well when both procedures are performed? ........tbc

Anonymous said...

Part Deux -

Thirdly, how common is it to do these procedures together and will the pain be potentially unmanageable? That scares me.

Fourthly, I have idiopathic nerve damage with small muscle loss in my lower extremeties x 12 years. This also affects my tongue and olfactory nerves, altering my sense of taste and smell at times. In searching for the causes of this through treatment at UCSF, nothing has been determined (except that it's slowly progressive) but it was discovered I have several hemangiomas (one rather large) on my lower spine. Do you feel this surgery would be contraindicated in any way due to my history?

Fifthly, after I have a bowel movement, and certainly when I am in dire agony when the fissures are open, I have severe intestinal cramping that subsides when the anal sphincter spasming subsides (2-6 hours). Is this referred pain, in your opinion? When the fissures temporarily heal, this pain is very minimal and even disappears entirely sometimes.

Lastly, (you really SHOULD send me a huge bill but I can't remember my address right now....) I am using 3 tbls. of ground flax seed for fiber as I'm allergic to psyllium. I'm also drink lots of water and have been using 1 capsule of Docusate Sodium 100mg. (stool softener) each night x 30 days now. Do you feel this is habit forming and would it be okay to continue until surgery to prevent a recurring opening of the fissure? How about after surgery?

Anonymous said...

Part 3 - (I don't know French and was just showing off in Part 2)

Okay, I lied. I guess the TRULY last thing I'll say is these stories about key-hole wounds and severe scarring leading to life-changing incontinence are horrifying. I'm so sorry for those who are suffering with this and will keep them in my prayers. Is there ANYthing you can recommend post-operatively that will lessen these risks? (I will follow your recommendations about mineral oil, etc. as I've read through every single post.)

No one told me that nine-years of birth-breathing (Lamaze) during bowel movements was abnormal. But why would they? It's not exactly something I ever shared as I figured it would be a regular party-coversation stopper. And I think I was right. I thought everyone experienced some pain and cramping after eliminating. Now I know better and you, and your forum, are THE best source out here for connecting. Once again, I thank you from the "bottom" of my heart.

The Verbose P.I.T.A. Woman

Sid Schwab said...

PITA: The decision on how to manage simultaneous hemorrhoids and fissures depends on the nature of both. If the hemorrhoids can be managed in a "non surgical" (ie, banding, injecting, etc) way, and if you're not in dire need of immediate surgery for the fissure, doing them sequentially can make sense. Typically the pain of hemorrhoid surgery is greater than that of LIS; that means, on the one hand, if you need operative treatment of the hemorrhoids, adding LIS won't make it measurably more uncomfortable. But if the only reason to do them surgically is because you're going to have the LIS anyway, it's worth considering staging them.

Remember, though, that, without knowing your anatomy, the nature of your 'rhoids, I, basically, don't know what I'm talking about.

Likewise, I can offer no comment regarding your neurological status. It's a question best directed to those caring for you for that condition, and/or your surgeon.

I doubt that post op behaviors have much to do with avoiding or getting keyhole deformities, etc; I think it's more to do with how the operation is carried out. All I've recommended is keeping the stools easy with mineral oil, etc, and warm soaks in the tub, for comfort mostly.

Finally, your questions are all good ones and you should feel free to ask them of your surgeon.

Anonymous said...

Hello, I said "functional," rather than for "cosmetic" purposes. The scar is causing leakage. Something's got to be done w/the scar.

Anonymous said...

Thanks so much, Dr. Sid, for taking the time to answer my book of questions. And just in time for the subject, my posterior fissure reasserted itself this afternoon. Though I'm scared of surgery, these events make me long for it.

Any thoughts on the stool softener, long term? Is 30 days long term? Can I continue without dependence? I don't think I can live through a full-blown reopening down to the muscle!

Thanks again and blessings on you! Your Friend, P.I.T.A.

Sid Schwab said...

PITA: guess the colace got lost in the morass. As it were.

I don't think there's a problem with long-term use of things that simply add moisture or bulk to stools. It's stimulants that can become "addictive." Colace isn't in the latter category.

Anonymous said...

"Morass" - Bwahahahahahaha! I could've waitied for a long time and never been able to remember such a great word for the subject.

I thank you kindly and will let you know from the other side. Hopefully, that means from the other side of the procedure.

Your Friend,

Major PITA

Anonymous said...

Hello Sid, I'm the one who told you I've had fecal leakage since my LIS over a decade ago. I also said I had sphincteroplasty done. Anyway, yesterday I went to a University Colorectal Surgeon where an anal ultrasound was performed. I was told I no longer have 180 degrees of my internal sphincter muscle. Maybe 50-60% of the muscle could be seen, and much of that was very thin. I was further told my only option (other than living w/incontinence) is to have an artificial sphincter surgically inserted. Tell me how I go from having a fissure for ~6wks to needing something this drastic? To make matters worse, I'm dealing w/internal and external hemorrhoids as well.

Sid Schwab said...

I can't tell you. Having never heard of such a thing, I have no idea.

Anonymous said...

Well, my question was meant to be rhetorical. My point is the medical community may think of LIS as a simple procedure w/minimal complications, if any - but I vehemently disagree, for obvious reasons. It essentially stole my life from me at the ripe old age of 29. Now at 41, it just keeps taking! I spend the majority of my days in or looking for restrooms when not at home. Wearing pads/diapers while in your 30s is not the most exciting thing to have to do. I barely make it to work each day, and have no desire to make any kind of effort while there. I'm thinking of applying for disability benefits, although I'm not sure if fecal incontinence is something that will allow me to qualify. Sorry for all the negativity, but what else would one expect?!

Sid Schwab said...

Your situation is indeed horrible, and I'm sorry to hear of it. But for those who come here for information, I'd just like to restate the obvious: there's no procedure -- or, for that matter, nothing in life -- the outcome of which is guaranteed.

Your result is so far out of the usual that, whereas I can't imagine a worse outcome, it doesn't reflect on the benefit of the operation, done properly and for the right reasons, for the vast majority of people.

For the record, and I imagine this has been mentioned to you already, if the situation remains intolerable or, god forbid, gets even worse, having a colostomy is to be considered. It would give you control: most people who have one at the far end of the colon can irrigate it every two or three days and forget about it in the meantime. A terrible price for an operation gone wrong, but the better of bad things, in some cases. I'm happy to say I've never seen someone who needed it; but it's among the solutions for intolerable incontinence, whatever the cause.

Anonymous said...

Sid, I appreciate your sympathy for my condition, as well as your mentioning of cholostomy. To be honest, though, there are no traces of a doubt in my mind that I choose to not exist "way" before a cholostomy or an artificial sphincter. I guess not having children gives me the luxury to think this way. If I were far older than I am, I might feel differently. But I'm not.

Anonymous said...

Can LIS relieve procalgia fugax and/or levator ani pain that persists >1 year after a surgery to remove a hypertrophied anal papilla? Could surgery (internal incision, closed with stitches - not just a ligation) have resulted in a tighter anal sphincter to the point it might induce symptoms that rival anal fissure? I know you can't diagnose, but can you comment on any known "pathology" to use Dr. language that would connect the two? The pain began immediately after the procedure, and has never gone completely away, although there are bad days and less bad days. Just looking for anything that might lead to relief.

Sid Schwab said...

Proctalgia fugax is somewhat of a non-specfic diagnosis; more of a symptom, really, that can be related to various causes including fissure and levator ani syndrome. Those are pretty separate diagnoses, the former being based on inspection and/or symptoms, the latter based on digital rectal exam. The best treatment for levator ani syndrome, as far as I know (and I don't claim complete knowledge) is direct and repeated massage of the muscle.

Although I have no direct knowledge of any way LIS could help with pain not related to fissure, I'd have to say it's pretty unlikely. Two different muscles involved, at least with levator syndrome.

It's possible there could be some sort of chronic infection/inflammation related to the papilla surgery, for which CT scan or MRI might be helpful to diagnose.

I don't think direct excision with closure would have been less likely to cause a problem.

KerrBear said...

Dr. Sid- I am 37 years old and I take good care of myself. I actually pride myself on how healthy I cook for myself and my family and how my family spends a lot of time outside rather than inside. BUT- I have a serious butt problem....After the birth of my 1st daughter 14 years ago I got a fissure and ignored it the best I could. Finally 2 years ago I went to a colon/rectal surgeon and he said it was a chronic fissure and asked how I dealt with the pain for so long. So I had LIS and felt better. After 6 months I began to feel another one and ignored it again. Finally 1 year later I went back and he performed a test that measured the pressure in my butt. He said it was off the chart high and he needed to correct it. So I had a more major surgery and it was like an anoplasty. The recovery was hard but in the end I felt great. He said to avoid jogging and lifting weights with my legs - forever. So I am a yoga and pilates person and walk on the treadmill. Well- this summer I was diagnosed with hyperthyroidism and it caused me to have several bowels a day. In return I got a nasty fissure again and this time it feels deeper inside my butt. I am bleeding and all the good stuff that goes along with a fissure. I went back to him and he gave me some cream and said to relax and try and get the spasms to stop. Well this week the spasms are really bad. I feel like I am back to square one. I plan on visiting him again this week but I am afraid he is going to say surgery. Any suggestions??????????
I am very upset.....
Thanks!

Sid Schwab said...

KerrBear, you've had way more than your share of problems. I don't think I can suggest anything worthwhile, since your surgeon is much more able to evaluate your situation than I am. It's good that you're staying with him. I can only wish that you once again will be able to say, as you wrote, "in the end I felt great." Pun intended or not.

Anonymous said...

Dr.sid instead of the LIS to control the spasms caused by the fissure what do you think about bio feedback or another type of therapy to learn to relax and be such a "tight ass" such as yoga or even plain exercise like walking. guess my question is once the muscle has gotten tight and begun spasming is there a way to teach it to relax back to normal or is the LIS the only way once its that far along..? ive been dealing with fissure for aprox. 2 years on and off, this last episode has been almost 4 weeks and not healing with horrific spasms ALL day and general surgeon recommended LIS. I get lots of fiber and water and my stools are never hard per say, but the least bit of bulk to them and wham i tear again. your thoughts please.
thank you,
big W

Sid Schwab said...

big W: I have no experience with patients who've tried biofeedback. By definition, I guess, I got the people who'd failed whatever therapy they tried, and they were in no mood to try anything else but surgery. I have suggested soaks in a nice warm tub, and I think that can help some.

I have read that biofeedback can be effective for anal spasms, levator ani syndrome, etc. I can't judge the quality of the studies, nor can I suggest how to find a practitioner with experience in that region. As it were.

Anonymous said...

dr. sid thank you for such a speedy response. my surgery (LIS) is scheduled for oct.5th i hope this works... my worst time has been with the stinging, hot knife pain from the fissure and the spasms are the most horrific for like 8-10 hours after a bm so hoping for some relief finally.....

big w

Anonymous said...

Oh! Somebody who understands. I have cancer. Chemotherapy sucks. But I also have an anal fissure. I've tried telling my doctor that I need HELP. That the anal fissure is much, much worse than the cancer and if something isn't done, I will shoot myself.

Anonymous said...

Hi Dr. Sid,

P.I.T.A. here. I told you I was having it done and I did - the LIS with the hemorrhoidectomoy (sp?) all in the same day. It was pretty horrible though I'm still glad I did it. I had to have a bowel movement 8 hrs. after surgery (due to them not doing an enema beforehand), and that landed me in the hospital for two days. The pain was at the screaming level off and on for three weeks. This double surgery is NOT for the faint of heart.

I think the surgeon did a great job overall and that insane sphincter pain is so much better. But the fissure persists even after the hemorrhoids have and stitches have healed and the pain from that is intense. Four weeks later I do not have my life back and I'm still bleeding and have a lot of pain from the fissure. The doc doesn't seem concerned (not in an uncaring kind of way, just like that's the way it is). But I AM getting discouraged about when to expect the bleeding to stop and the fissure to start closing.

As soon as I have a b.m. each day, I can expect hours of pain and no activity or driving due to needing to take my pain meds and the level of suffering. I don't LIKE pain meds and wonder how ANYONE could get addicted. I take as little as possible but the dr. says to continue because he doesn't want me to suffer as long as they aren't constipating me.

I'm taking Metamucil (allergic to psyllium), Colace x 1 or 2 and lots of water. The mineral oil makes me feel sick to my stomach but I may go back on it.

Any thoughts or encouragement about how much longer I can expect bleeding and pain? I so appreciate your forum here.

If you tell me it's still possible to heal and the fissure is probably not a permanent part of my life, I'll feel encouraged even if it takes me longer than the average bear.

Thanks, Doc.

Sid Schwab said...

PITA: there's no doubt it's still possible to get all healed and happy. Four weeks is longer than average, I'd say, to still be having that much pain. The bleeding, unless it's a lot, isn't a worry at this point, I'd say (without knowing the details, yada yada...)

All I can say is to stay in touch with the surgeon, keep your bm's as soft and easy as possible for now, maybe soak in a nice warm tub a couple of times a day. At some point, if there isn't further improvement, an exam under anesthesia might be in order.

Anonymous said...

Sid - I have been a sufferer of Annal Fissures for a number of years - 4 to 5 at least. As history I have dermititus hermitiformus - an allergy to glutin and try to eat at glutin free diet, but a 100% glutin free diet is tough. I also am told I have IBS and the doc prescribed a double dose of Citrucel morning and night. B oth of these conditions predate the fissures. When the fissures showed up the doc said to eat more fiber, easier said than done... Some things work and some don't. I now have a diet that begins in the morning with 3- 4 teaspoons of ground Flax seed in my Corn Bran cerial. Lunch is yogurt, with 2-3 teaspoons of flax seed and an apple. Dinner is whatever is beign served with as much roughage as possible. When all goes well my BMs are very soft and i get by ok, but it takes almost nothing to cause a new fissure. The operation sounds like it works for some people, but not all.
Took a trip to Spain in the middle of a serious bout and found to my releif that a diet of cheese, fatty meats (iberian ham etc)seemed to "grease the tubes" and I got a long fine as soon as i got over the constipation that seems to get me when I screw up my time clock.
Question - Does anyone ever really recover - fully from experiencing annal fissures?

Sid Schwab said...

Yes. I'd say by far most do. On forums such as this and many others, no matter the disease or operation in question, one tends to hear from those who have problems. The denominator, however, is unknown. In other words, forums give voice to those who chose to post about problems.

The vast majority, who do just fine, whether it's this surgery, or gallbladder surgery, or whatever, don't speak up because they're happy and don't need to.

Anonymous said...

Hey Dr. Sid,

Thanks for the encouragement. I'm still doing the tub soaks a couple of times a day and realizing I was getting a little lazy about water. Please people: drink a LOT of water. I have to do a minimum of 100 oz. a day or no matter what, I can't keep my bm's soft.

The bleeding continues but is a little better. My husband remembers the doc saying if could be from a new hemorrhoid that formed with that bm 8 hrs after surgery. PLEASE everyone ask for an enema before surgery ( or do it yourself) so you don't have to go right away. That area needs a LITTLE rest.

Still "movin'" along. I'll let you know when I'm all well. Can't thank you enough for being here!

Anonymous said...

P.S. Sorry, that was me, PITA. :)

Anonymous said...

I am a 37 year old woman and had my first child a coupe of months ago. When I was having pain going to the bathroom I just assumed I had Hemorrhoids but it never got better with any of the common treatments. My Mom then said that it might be a fissure (she has unfortunately suffered with them for 25+ years poor woman). So I went to a Dr. and I did in fact have 2 anal fissures. I tried everything the first 6 weeks, creams, sitz baths, heating pads, more water, more fiber (did not work for me at just made my BM too voluminous) and nothing seemed to make a difference. Then I had a thought that perhaps the fact that I was still breastfeeding may be making a big difference in how much hydration was being used to produce milk. So I made the very difficult decision to stop breastfeeding earlier than I was planning to. Within 2 weeks I was feeling much better and although I still have to use Vaseline before each BM and I still use creams and baths it was becoming much more manageable. It has recently gotten worse again (I think due to taking some diet pills that make me really thirsty and not keeping up with drinking enough water) but I am trying to stay positive, although that is very hard and I see from all posts I am most definitely not alone. My main reason for posting was for any new Mom who is having this issue to consider stopping breastfeeding to see if that helps to speed your healing as it did for me. Again hard decision but in the end it was the right one for me. I truly wish everyone who suffers with this the best of luck, this is perhaps one of the hardest things to deal with (I know it gets me depressed more often than I would like to admit) and not the easiest thing to talk about so it's nice to have a forum to do so, thank you!

Anonymous said...

Hi Dr. Sid,

PITA here. It's just after four in the morning and I'm laying awake contemplating my pain and doing exercises to try to get relief. I'm six weeks post op two days ago. I go once a day but always have bleeding, sometimes so much that I can't see my stool. Is there a risk of anemia from this level of bleeding? Also, each bm brings on hours of severe anal and abdominal/intestinal pain that is certainly life-changing. I feel myself sinking into depression.

I cannot sit, experience tailbone pain as well, and yet still keeping the Norco/Valium to one per day (unless absolutely out of my mind with pain) wherein I will take two Norco hours apart. I am a humor writer by trade and I haven't been able to write because of the pain and not being able to sit at my computer.

It does NOT hurt to go to the bathroom even with the bleeding.'the pain starts ten minutes later and "blooms," if you will, steadily ratcheting up to sometimes unbelievable proportions and lasting hours and hours. It makes me SO afraid to go to the bathroom again that I sometimes don't eat all day just so I can avoid pain meds, drive, and do for my family what must be done. This has me eating dinner only, though I still drink 100 oz. of water through the day. Then I wake up half-an-hour after going to sleep to go.

I'm still doing sit baths and hot packs but not feeling very hopeful. Any thoughts?

Sid Schwab said...

My first thought is to feel bad that you're so miserable. The second is that you're out of the norm for expected post op course, and you should see your surgeon again; if he/she isn't of help, then another opinion is reasonable.

Anonymous said...

I am so thankful for you site. I'm doing all the self help measures - several warm baths per day, increased fluids, increased fiber (slowly), citurcel 2x per day, colace stool softener 2x per day. My OB/Gyn rx'd Nifedipine for me. I had asked for it and he didn't really know much about it. I was just told 3x per day "for external use only".

What is the most effective way to apply Nifedipine gel. I am dedicated to getting better!! Does it need to go inside the anal canal?

Also, I have an annoying "sentinel pile" to go along with my fissure. Could I have it removed without having the LIS surgery? Could any doctor (my OB/Gyn) do this or would it need to be a CRS?

My heart goes out to all that are suffering with this type of issue!

Thanks for your site!!!

J

Sid Schwab said...

A sentinel pile is easy to remove, and any general surgeon could do it; it needn't be a CRS. I doubt an OB/GYN would want to, for generic reasons, but it's simple. Depending on pain from the fissure, it can be done in the office. The area of the pile is painless, so there's virtually no discomfort -- other than getting there when there's an active fissure.

Nifedipine works best when applied directly onto the fissure, which means putting some on a finger tip and gently inserting it a little way in. Same with nitroglycerin, which also can work.

Anonymous said...

J here again. Thanks so much for your reply. I guess I have a few more questions about Nifedipine. If you apply it first thing in the morning and then have a BM 2 hours later, should you reapply it? Does it work topically or is it absorbed into the blood stream and work that way?

Is it supposed to relax the spasm instantly (I'm don't think it is in my case) or does it take a bit to do so?

Is it normal that is sometimes stings/itches for a bit after using it? Anything I can do to make it not? My version doesn't have any lidocaine or anything like that in it.

I am so ready to start feeling better!!!

Thanks again for all you do!!!

J

Sid Schwab said...

It works mostly topically. There may be some effect by taking nifedipine by mouth, so absorption could be part of it, too. It should be applied twice a day. I'd suppose that by the time two hours is up, it's been taken into the muscle so I'd guess it doesn't need to be reapplied after a bm two hours later. But I don't know for sure.

It's to be expected that there'd be stinging or burning for a while after application. It doesn't work immediately. You could try lidocaine, I suppose, but I'd not want to dilute the nifedipine.

SMR said...

thank you, thank you, thank you for taking the time to offer your expertise and to establish a forum for AF sufferers to share. Here's my story in brief: During birth of my last child (21 years ago!) I developed a fissure. Thought it was hemorrhoids for about 12 years. Had surgery scheduled once but got scared and canceled. Been able to keep the demon-down-under at bay with stool softeners until recently. Here's the question: When the AF acts up, are there things that exacerbate the condition? Such as lifting, exercise, car trips, etc. I am scheduled to go on a three-hour-car trip this weekend and I am NOT looking forward to it. Wondering if it will just bring pain or if will actually hamper the healing. Again...thank you for so generously sharing your knowledge.

Sid Schwab said...

SMR: I don't know of evidence that those activities retard healing, but they certainly can add to discomfort.

voon said...

Sid

Had a lateral sphincterotomy done on 9 Sept. No change in my severe pain. Seen my surgeon 3 times after surgery. On my last visit one month ago, I was warded by him for pain treatment. Was in hospital for 8 days treated mainly with different painkillers but my pain worsens because the painkillers constipate me. Was discharged 2 days ago. Very little answers from my surgeon who gives me the standard answer "Is healing"
The pain does not come from the wound but the same spasm pains that I am experiencing for the past 6 agonising months. The only difference is that after surgery,no more bleeding after bm. He seems unsure what to do and prescibed more painkillers. Should I seek another opinion? My pain is driving me crazy. Help!!

Sid Schwab said...

voon: it doesn't seem right that you had that much pain after the procedure and that you still do. I'd seek another opinion, preferably from a colorectal specialist.

Anonymous said...

I am the mom who left some comments about 2 weeks ago (10/3). Since my re-occurance recently I have tried to do what another person on this blog recommended - sitz baths and heating pads and I feel like I am on my way to healing. I also add epsom salt to the bath. I know I read somewhere about a product from "Dr. Wheatgrass", I found it and tried it. Some people on the site said they felt better after 1-2 days of using it. I was very skeptical since I had tried hydrocortisone, nitroglycerin etc - all the perscription creams you could think of. Well I am happy and surprised to report that after using the cream for a day and half I felt like I was 150% better!!!! I just wanted to share what worked for me - I drink a lot of water, take a sitz after each BM and before going to bed, Whenever I am sitting down I am sitting on a heating pad, I take 4 stool softeners each night, I take 2 magnesium glycinate pills every night (I have been taking these for years for constipation and use them religiously) and I apply the Dr. Wheatgrass skin recovery cream every morning, every night and after each BM. Also I try to inject vaseline before each BM to lessen the likelihood of a hard stool aggravating the area. I also make a batch of the lentil/okra stew recipe that someone posted on here to aid in keeping me regular. But I would highly recommend the Dr. Wheatgrass skin recovery cream - again I was extremely skeptical but desperate to find something that would work and it does!!! I just wanted to share my experience in the hopes it can help someone else with this life consuming malady!

Sid Schwab said...

In general I don't publish comments that seem to be thinly-veiled commercials. In the above case, I can't be sure, although the mention of the name several times is suspicious.

However, if people want to spend a lot of money on a cream of questionable medicinal value, I doubt it'd cause harm to anything but the pocketbook; and if it works, that's great.

Anonymous said...

I am the one who posted about the cream - I am not affiliated with the company nor would gain anything from promoting their products. I just know that so many people keep posting what they have done that doesn't/didn't work and my husband and I were so surprised that this cream worked better than the prescriptions I was using for the past 3 months (which also cost a lot of money, especially for the compounded creams) that he told me to let others know about it. I noticed that with a lot of chronic conditions you usually find more people actively posting on blogs looking for answers or complaining about symptoms, rather than people who have successfully overcome a condition, so I figured it may behoove someone to at least know that the product is out there. I was going to just go about on my merry way singing a happy tune with a healing fissure but wanted to re-visit the site and share my experience. I would leave my name but with a malady such as this and having a unique name and the internet being so public I would prefer to stay anonymous. But please don't think I was in any way hawking it, also as you can see I am doing 10 other things in tandem - it is a constant battle to keep myself on the road to recovery since I am opting to not go the route of surgery. I know that many physicians are skeptical of any treatments not approved by the FDA etc. (as members of my family are doctors) but sometimes natural remedies work wonders. Ten years ago I was suffering with a lot stomach issues (constipation mostly) and went to numerous physicians and had numerous tests done and found no relief. After doing a lot of research on-line I read that taking Magnesium Glycinate (just a mineral not a branded product) can help alleviate constipation. I started taking the MG and after some trial and error of when to take it and how much I have been almost constipation free for about 8 years. I certainly understand your concerns Dr. Schwab as when I researched the cream myself I was very skeptical as well. I appreciate that you did post my post nonetheless and if it helps even one other person I know it was worth sharing.

LAF said...

Short version, 52 year old female, fissure pain for 2/12 months, saw a CRS , diagnosed with a chronic stage fissure in the 6 o' clock position not far into the rectum, using diltiazem 2%. Getting some relief. Not at the "kill me or cure me" stage... yet. The info on your web sight has been enormously helpful. Question...Why do we not hear more about the use of LASERS for this hideous condition?? I have read other stories on other websites where LASER has been used very successfully on AF sufferers.(some by emergency room dr.s) Lasers have been proven to be very effective on a number of conditions lately, is very safe, non-invasive, short recovery time, and hardly any side effects, AND significantly cheaper than surgery. To an average person like me, if this is true, then it seems to make sense, the only barrier to this new procedure to be furthered studied, used, suggested and/or promoted is the fact that it is so much cheaper than surgery. With all due respect, Dr.Sid, we all know its about the dollar, and CRS and GS would take a monetary hit if this procedure proves to be successful for AF sufferers, especially those less chronic. I understand you are retired and that may be a reason you don't know a lot on this subject, maybe you do, but would you please find out more if you could?? Opinion, please???

Sid Schwab said...

Oh, how I love these "it's all about the dollar" comments.

Laser is all about the hype.

Okay, it's not always. But the laser is a way to cut or to coagulate tissue or otherwise to destroy tissue. It's not magic. A cut is a cut. Whether by laser, cold knife, electrocautery, a cut is surgery. It's not "non-invasive." It'll hurt as much as a cut by a knife. I have no idea what an ER doc would do with a laser for an anal fissure, but I can tell you that whatever it might be, without anesthesia, it'd hurt like hell.

Laser is not a magic ray. It doesn't have healing powers by itself. It's a very hot beam of light. It has certain advantages in the ability to use it in hard to reach places, since you can bend it via fiberoptics. And it's good on tattoos.

In and of itself it's neither invasive or non-invasive. It's the technique by which it's used. On skin, yeah. Non-invasive. On a gallbladder, after punching holes in the belly wall, it's exactly as invasive as electrocautery, but slightly less easy to control.

Want to know all about the dollar? Find out how much a laser unit costs compared to standard electrocautery. Read how many laser machines were sold to hospitals because "that's what people want." Check out how many of them are gathering dust.

Or, read this. Or this.

So, yeah, I guess you're right. It's about the dollar: the ones collected by companies that make lasers, hype then to a gullible public, and sell them to hospitals who don't want to get left behind. Or so they thought.

Sure, there are hucksters out there selling some sort of laser technique or other for just about anything (some of which aren't even using lasers.) And there will always be people who fall for it. Like magnets, homeopathy, and manipulation of the spine for asthma.

Sid Schwab said...

P.S.: I don't know any general or colorectal surgeon who wouldn't LOVE never to see another fissure. It's not just a pain in the ass for the patient. So go out there and gather ye your laser hypers and take every last fissure patient with you. You'd have the undying gratitude of everyone.

So, go for it. And thanks for stopping by with your insults. It's why I keep doing this.

voon said...

Hi Sid
Voon here again. After my posting on 10/15, I did seek a second opinion from a CR surgeon.(My first surgeon is also a CR surgeon)

After reviewing my case, he told me that my pain is due to my sphinter muscles "working overdrive" to expell the load of fibre and stuff from my body.I have to lessen the burden on these muscles to ease my pain. He told me to stop eating fruits (juices are ok), vegetables, oats and fibre I have been taking to smoothen my stools for a easier bm. He assured me that I won't get constipated by drinking plenty of water and 20ml of Lactulose a day. I have to do that for one week before the next appointment. I am totally confused because what he advised go against all that I know about AF. He told me that my fissure has healed after examining with his finger only. He is a leading CR surgeon and in fact one of his papers on "advanced flaps" was actually cited by you in this very blog last year. I am still in shock. What is your advice to me?

Sid Schwab said...

voon, I can't give better advice than someone who's actually examined you. Given varying opinions, you'll have to decide whose to follow, and then stick with that person long enough to see it through.

Anonymous said...

I was enjoying the helpful stories... until LAF seemed to get under your skin, in your P.S. reply. I thought you were a little harsh to say the least. Not only to her, but all AF sufferers, and possibly your future AF patients, if you have any after reading those remarks. At the beginning of this site you state what an embarassingly simple operation this is and only takes a minute or two at most. I'm sure you are paid extremely well for your competency as a great surgeon as you should for having to suffer through those 2 grueling minute. Using your own words, those 2 minutes are a pain in your own ass. Excuse me...your insult was felt by all your bloggers that are AF sufferers. I think your beef is more toward the holistic medicine. The 2 field of medicines seem to clash and it's my opinion your snide remarks only proved her assumption right... it is about the holistic field taking money out of the Medical Doctors pockets. It is a shame because there is a place for both fields of medicine. I know your not going to post this, but I got pleasure in knowing you will read this...

Sid Schwab said...

Yes, I admit that person's claim that it's all about the money, and that since I'm retired I don't know what I'm talking about annoyed me. Especially because I keep giving helpful answers here long after I've stopped making new posts on this blog.

Yes, I find it frustrating that people are as gullible as they are; and that people would stop by this entirely voluntary thread to insult me.

As to the comment about the operation being a pain in the ass to surgeons: it was in response to that person's claim that it's all about the money. For that two minute operation, for which the reimbursement is a few dollars, we have to do a history and physical, schedule it at an operating room (in my case, I usually did it as an urgent procedure, interrupting my schedule and, since it wasn't a true "emergency," taking an OR time late in the afternoon), get there ahead of time, meet again with the patient, do the procedure, dictate an op note, write orders, see that they recovered okay, and follow up with subsequent office visits: all of which adds up to several hours and all of which, including subsequent visits, is included in the surgical fee.

So it's the opposite of a money-maker. It's a service to those in need, which I was always glad to do. But when dumped on by someone suggesting we withhold better treatment to line our pockets, it makes it hard to be nice in response.

I invite people who are angered by what I'm doing here, for the benefit of those who are suffering, to stop stopping by.

And if I'm human enough to get pissed off when this entirely voluntary effort is used as a way to insult me and all surgeons, well, that's the way it is. The fact is, I spent more time on the answer than the comment deserved. The P.S.? Well, it is what it is. Probably I should pretend not to be ticked off by such claims. I could delete it, but I won't.

Sid Schwab said...

P.S.: Thanks to the last two commenters (excluding voon) I'm closing comments in this thread.

To those AF sufferers who stop by, if you wade through the many previous comments and my answers, it's likely you'll find something that relates to your issue. If not, I'm sorry; but I really can't offer much but general information, most of which is already here in the post and in the comments.

If you are suffering before or after surgery, the best and only advice is to keep letting your doctors know what's going on, and to seek other opinions if you remain unsatisfied.

Sorry it ends this way.

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