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. Here is a link to what I had to say, in the brief time allotted, about anal fissures.
331 comments:
1 – 200 of 331 Newer› Newest»Now, many are trying "off-label" use of BOTOX for chronic anal sphincters [http://www.medscape.com/viewarticle/524042_2]. I think which ever method you used--you'd still be a hero.
You're right, Sid. It's the little things that make the biggest impact. I remember when I had a horrible earache. Convinced I was going to die, I raced to the doc and he liberated all sorts of hardened and impacted wax. I was in too much pain to be embarrassed at what I thought was terrible hygiene. Turns out I have tiny tubes. After he finished, I was so grateful, I kissed his cheek. Ten years later, he still remembers that.
So when the Great Cosmic Muffin is busy redesigning the anus, can we put in a work order for tiny ear tubes, too?
No wonder you love what you do! You get to use your skill and help people.
Indeed, it must be quite satisfying to successfully carry out the big and challenging cases. They all matter.
Dr Schwab, you are very right!! The small surgeries are as important as the big ones. I love my lady surgeon....whom I was looking for a few years..the woman, who would do it for me...the stapling of my hemorrhoids...as much as I do the brilliant back surgeon, who did the spinal fusion on me! Because of both of them I'm walking again perfectly!
Good God,
Well, now at least I know what to look out for if I ever have an anal fissure. That sounds horribly painful. Ouchie.
I love the lateral internal sphincterotomy. Such a satisfyingly underrated operation. The way the thickened, spasmodic internal sphincter muscle fibers suddenly relax when cut, the entire anus chilling out finally. .....do you routinely excise the fissure?
Not routinely. Usually not, in fact. Yeah, that release: it's the precursor to happiness.
Two thoughts from a sufferer...
1) Botox was fairly useless to me - less relaxation than nitro creme
2) Somebody who re-occurs may have a constipation problem rather than a defectation problem.
And yeah, it is really painful.
Oh yes... Years ago, I caught my fingertip while closing a door and ended up with a huge blood blister under the nail. I still remember the incredible surge of relief when, after 24 hours of searing agony, my GP heated the end of a straightened paperclip and simply popped it through the nail.
anon: yes. It's constipation that causes those tears-in-the-eyes bowel movements, and that's why fiber (to avoid constipation) is the best long-term prevention.
Joe: glad you mentioned that: I really enjoyed doing that little treatment. It's instantly effective and brilliantly simple. Primitive, even.
Equally fast relief: poking a hole in the side, and applying suction to relieve a pneumothorax. I went from breathless agony to easy happy breathing in under a second.
Well, it's too late for anyone to probably read this, but this is the end of a story that brought tears to my eyes (from laughter, not anal pain) when I first read it years ago. It's a clearly more primitive procedure (I know the story is exaggerated for humor's sake, but I doubt the actual procedure is made up); just wondering if this was actually the standard some time ago.
I solved my own anal fissure simply by the way I sat on the toilet. I had a fissure for about 6months. I realized that I arched my lower back which caused the colon to "arch". When I round my lower back out, the bowel exits out more straight versus scraping/rubbing against the posterior part of the colon/sphincter. As soon as I did this, the fissure was gone in a week or so...so the trick, at least for me, was to round the lower part of my back (like the scared cat position in yoga but instead the lower back). Hope this helps some of you!
I am having the worst fissure for the last month but I will try this and see if it works.
PP
26/01/08
Have just found out I have an anal fissure and don't know if I want surgery or the creme stuff. So you are saying the surgery is best?
No. I'm saying that surgery usually works. In most situations, it's appropriate to try non-surgical treatments first. But it depends on various individual factors; the best decision can only be made by you along with your own doctors.
I have an anal fissure of about 6 weeks. But I eat a lot of fiber! Could it be the Lexapro, Phentramine, or Laci La Beau Super Dieter's Tea, which consists largely of senna herb? Also, does it change the consistency of your poop? It is now not smooth on the outside and looks kind of like a tater tot or a sponge or something?
Most fissures occur as a result of passing very hard bowel movements which tear the lining of the anal canal. If your bowel movements have not been hard and difficult to pass, it could be from another cause. I'm not aware of any medications that cause them. It's important that other issues are ruled out if it fails to heal.
I hate to argue the doctor's opinion but isn't it strange to fight anal fissure with making another wound in the.... ehm.... yes? Here's an interesting view to the anal fissure surgery
What's to argue? Did you read what I said?
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.
It happens to work, and dramatically. Your argument is like criticizing firefighters for lighting backfires when fighting a forest fire.
Sid, I suffer from fissures but they only seem to last maybe 5 days when I get them. I am very regular, going at least once a day and take plenty of fiber, fruit, and vegetables. I hate these things and nitro seems to work but they keep coming back. I have had a colonoscopy and that came back very good. Is surgery my next step? I dont seem to have them as bad as what I have read although even the small ones hurt like hell. What do you think?
that's an unusual history, all right. I suppose if nothing keeps them from coming back, some sort of intervention would be a consideration
Since I really can't make specific recommendations about a case with which I'm not personally familiar, I'd just say a consultation with a colo-rectal surgeon would be a reasonable consideration.
Have had one. Like i mentioned I am never constipated, very regular, and healthy with and active lifestyle. She to has narrowed it down to an overtight Sphincter since I really have none of the typical things that go along with fissures. I am fortunate in that mine heal fast. As I mentioned before I had a colonoscopy and that came back perfect. I asked here how the area looked where my fissures occur and she said If she was not the one who has been seeing me for these it would be hard to tell that I suffered from them since there is very little evidence of scar tissue in the area. She said I am the lucky recipient of an over tight sphincter. Any idea how to relax it without surgery?
stretching under anesthesia (sometimes referred to as the Lord procedure); and botox, are among the options.
Stretching has a high incidence of incontinence right? My thought is to have surgery and go with what has the highest success rate. Is the recovery period long? And in your experience is this a very painful procedure to recover from (lis)? Also, can botox really help? I never got these when I was younger and started getting them in my mid 30's. I am 39 now and they are becoming more frequent.
Thanks
Had colon cancer & had colon & 90% of rectum removed & a "J" pouch made, all just short of two years ago. I am an active 76. Getting along fairly well with 8/10 bm's per day, but bothered by an anal fissure. Have tried many creams & oinments along with special diet without success. Doc is suggesting botox, but hesitant due to possible loss of bowel control. Any advise or suggestions.
That's a tough one. (First of all, it's great that you're getting along so well. That's a big operation.) Since most fissures, at least as I see it, are due to tearing from too-hard bowel movements, it seems unlikely yours is of that origin; therefore, botox or any other treatment aimed at relaxing the sphincter doesn't seem to make sense (understand that I have no ability to judge from this far away, so any comment like that must be seen as a pretty wild guess.) I'd want to be sure that the fissure isn't due to something else: a small biopsy might be a consideration. I assume your are getting advice from your surgeon; if not, you should. If so, depending on how many of that operation he/she does, perhaps a consultation at a place where they do bunches of them.
I'm curious why you had a total colectomy: did you have multiple tumors, or ulcerative colitis?
Yes, had UC for many years. Cancer was near where the small intestine & the colon join. Did not have a choice on the surgery. Surgeon says botox is highly successful, but not a permanent solution.
Sid,
Is the recovery very hard after LIS? I am in my late 30's and have small children and really do not want to be down for any length of time. I have been told that the only reason I get fissures is because of an overtight sphincter. will the surgery fix this permanently? I want these things to never happen again.
As I said in the article, for those with painful fissures, the relief from surgery is usually immediate.
There's no guarantee the effects will be permanent; the best prevention is taking dietary measures (plenty of fiber and liquids) so that your bowel movements have bulk but are not hard and are easy to pass.
I had the LIS surgery for a fissure about 10 years ago. I immediately had relief from the pain, but also immediately had a lot of fecal seepage after every bm. The seepage would be around the size of a baseball on the tp. After many tests and conservative attempts to fix this problem, a colo-rectal surgeon finally decided to give me a sphincteroplasty (about 3 yrs ago). After surgery, the surgeon said there was a very large gap to fix, leading me to believe way too much muscle was cut during the sphincterotomy. Since this surgery, I still experience the seepage, maybe a golf ball size on the tp @ it's worse. My current doctor believes my problem is the scar left behind after the surgeries. He calls it a "guttering" problem. After 10 long years of this, I'm mentally exhausted and need it to stop. Does anyone know what can be done about the scar, if in fact that's what the problem really is? Would some sort of plastic surgery to remove it likely help or make matters worse? Thanks.
It's impossible to know without being able to examine the area. My only suggestion is to get still another opinion, after researching for surgeons with special ano-rectal reconstruction experience. It would likely be at a "tertiary care center," meaning a place that takes complicated referrals, such as a university medical center.
Thanks for the quick response sid. A university med center is where the sphincteroplasty was performed. I've seen just about every colo-rectal surgeon in the Chicago area, and have essentially been turned away @ every stop. Many doctors told me that a sphincteroplasty was impossible to perform on the interior sphincter muscle - but fortunately I found someone to do it. One told me I have a keyhole deformity, even though the incision was made laterally. I think my only option @ this point would be scar removal. Do you know if this type of procedure has been done often, and if so, what is the success rate? Conversely, what if any negative results have occured?
Thanks Again!
I'm sorry, but I have no experience with nor particular knowledge of that procedure.
Okay, can you speak of what type of things can go wrong during a sphincterotomy that might cause such severe fecal seepage?
SId, read with interest your article about anal fissures and the surgery involved, along with all of the comments. I am a 49 year old female, active and healthy. I have had rectal bleeding associated with an anal fissure on/off for qbout 15 years. I tried the topical treatment which was not very effective and the doc wanted to do surgery right away (seemed too eager) and said it would be a 6 month recovery. I am an airline pilot for a major carrier so maybe all the sitting contributes to the problem. I can't afford to take 6 months off, nor put up with leakage. How do I find a good doc ( live part time in Anchorage AK and Naple FL) for a good checkup and who will try alternatives to surgery before taking that step. And yes, I have constipation problems that neither straight fiber/water or vegie/fruit diets seem to help. Sorry to be so long winded, but I'm getting desperate....DR
denise: since the main symptom of fissure is pain, I'd wonder if your problem is something else, like a fistula. In any case, it seems that seeing a colo-rectal specialist would be a good idea. A six month recovery sounds really long to me, no matter what procedure were chosen; so getting input from someone else would be useful. I'd think the person to seek out would be a colo-rectal surgical specialist, one with specialty training in that field. In selecting one, I'd ask about fellowship training. I'd guess there'd be more choices in Florida than AK, but I really have no idea.
Hi, I had LIS surgery 4 weeks ago with a tertiary level colorectal surgeon in the Bay Area. The fissure has reopened at 4 weeks post-op, after healing temporarily. I had had the fissure for several years previously with intermittent success trying nifed, botox, etc. My surgeon has said it is possible that she was too conservative cutting during the LIS--do you think it is unusual to have a second LIS if the first one fails? I'm concerned that I'm a "chronic fissure former" and worried that a second surgery may not alleviate the problem either. Thanks, A.
Jasper: it's not common, but reöperation is sometimes necessary. I can't really say (nor, I suppose, could anyone else) what the outcome will be. It's really important, no matter in what way a fissure is cured, to maintain proper bowel habits, meaning having enough fiber and moisture to provide bulky, formed, but not hard stools that are easy to pass. But, I assume, you know that by now and have figured out a way to achieve it.
Hi Sid--yes, you're right, I already have the bowel habits thing down to the best degree I can manage, life stresses notwithstanding : ) But I have been reading medical journal articles comparing outcomes between groups who had division of the sphincter up to the dentate line vs to the fissure apex -- it seems to me like for some people, the fissure apex might not be sufficient but that the only way to tell would be trial and error or 2020 hindsight. What happens to that 5% of people who don't have successful surgical outcomes?--a lifetime of anal hell?? Thanks, A
Jasper: I may not be the best to answer, because my method had nothing to do with such landmarks: by applying stretch one can feel the demarcations of the sphincter, like a taut rubber band, and can feel it "pop" free when cut. My practice was very broad in general surgery, and didn't include such great numbers of fissure patients that I didn't have experience with failures.
I have had an anal fissure for about two years now since the birth of my son. My stool everyday is almost liquid as I take magnesium to soften it. I have tried to allow it to heal naturally but it has these horrible set backs and it cannot tolerate any firm stool like normal stool that everyday people have. My life is hell, and i need a reliable good surgeon to give me by behind back and my life back. I have been from doc to doc and they all say try to heal it naturally first, i think i have been patient enough! I want to kil myself about now!!! HELP!!!!!!!!!! my main fear is incontinence!! I also want more kids in the future and I am afraid to do so :( :( :(
anonymous: it sounds like you need some different advice. Keeping your stools liquid for that long is exactly the wrong way to go. You need to consider seeing a colorectal surgeon. There are ways to heal without surgery; I don't know what you mean by "natural," but I'm always a little suspicious of that term in a medical context.
Hi Sid,
I have several questions:
Part 1
I saw a surgeon and I have a fissure and I've been messing with this about a month or so now but I'm thinking about going to a different surgeon because
#1- I didn't like him too much or his staff
#2- Secondly, (and more importantly) the medication prescribed is not helping and it's expensive. However, the biggest issue I have is while researching the 2 prescriptions I have come to the conclusion that they don't seem like a very common or popular solution
One is a suppository of Neomycin Suppositories. The other is a topical compound of Diltiazem/Lidocaine
These are not listed as a common treatment of ANY of the MANY sites I've researched.
2nd Part
I just started sitting in the bath over the last couple days and I've been doing them right after the bowel movement. The pain during the bowel movement is still there but seems to not last as long anymore. Is this due to the bath or possible healing? I stay in there about 60 minutes.
3rd Part
Is it better to sit or stand? Rest or be active?
4th Part
Diet- I am moving towards a high fiber diet and will be going with Metamucil, high in fiber foods, lots of water and stool softeners. My question is that I'm a drinker and I've cut back on beer because I was worried about the dehydration and creating a hard stool. I actually switched to wine so my consumption is much less. Can I still drink tons of water, high fiber diet, etc...and still drink? How does this affect my immune system?
5th Part
I know that holding your BM's will create a harder stool as that water gets absorbed but isn't it still possible to have soft stools but only every other day vs. every day? I think the ideal stool is around 75% water but that can still be achieved not having a BM every day if you are drinking and eating correctly. This would also give you more time in between to help heal.
I apologize for the length of this but I really appreciate your help!
Part 1
I saw a surgeon and I have a fissure and I've been messing with this about a month or so now but I'm thinking about going to a different surgeon because
#1- I didn't like him too much or his staff
#2- Secondly, (and more importantly) the medication prescribed is not helping and it's expensive. However, the biggest issue I have is while researching the 2 prescriptions I have come to the conclusion that they don't seem like a very common or popular solution
One is a suppository of Neomycin Suppositories. The other is a topical compound of Diltiazem/Lidocaine
These are not listed as a common treatment of ANY of the MANY sites I've researched.
I've never though topical antibiotics, like neomycin, are helpful. Diltiazem, however, can work, as can other topical agents that relax the muscle.
2nd Part
I just started sitting in the bath over the last couple days and I've been doing them right after the bowel movement. The pain during the bowel movement is still there but seems to not last as long anymore. Is this due to the bath or possible healing? I stay in there about 60 minutes.
The bath helps to relax the muscle, which is a good thing. It may be healing as a result of that and the other things you are doing.
3rd Part
Is it better to sit or stand? Rest or be active?
Doubt it matters either way.
4th Part
Diet- I am moving towards a high fiber diet and will be going with Metamucil, high in fiber foods, lots of water and stool softeners. My question is that I'm a drinker and I've cut back on beer because I was worried about the dehydration and creating a hard stool. I actually switched to wine so my consumption is much less. Can I still drink tons of water, high fiber diet, etc...and still drink? How does this affect my immune system?
No comment on drinking. The aim is to have bowel movements that are bulky (to help stretch the muscle) and moist enough to pass easily.
5th Part
I know that holding your BM's will create a harder stool as that water gets absorbed but isn't it still possible to have soft stools but only every other day vs. every day? I think the ideal stool is around 75% water but that can still be achieved not having a BM every day if you are drinking and eating correctly. This would also give you more time in between to help heal.
In my opinion, timing is less important than quality.
I have been seeing an "Enddarmspezialist" (proctologist) in Germany for 4 months for anal pain, but I'm still experiencing exactly the same problem: a strong (but not sharp) pain in my anal canal (not on the outside). Sometimes on the left side, sometimes on the right side. Some days are good, but most are bad.
The facts:
1. BM's do not hurt. 2 hours later it often aches deeply and strongly however.
2. I take Mucofalk (psyllium husks) for softening.
3. Sitting makes it worse.
4. Standing for long periods makes it worse.
5. Vibrating seats (in a car or tram) definitely make it worse.
6. There is no bleeding.
7. Sometimes I have aching pains down leading from my anal canal down the insides of my legs.
8. Sometimes I have hard painful lumps outside my sphincter which go away in 2 days or so. I think these are unrelated?
My doctor found a very small anal fissure which has since healed. He is now at a loss as to what is causing my pain. He gave me Lidoposterine (topical anaesthetic) and Hydrocortisone zinc paste which I have used for 4 months. He's run out of ideas, and wants to refer me to a surgeon!
This is ruining my life, and I've been having suicidal thoughts, which is completely ridiculous but worrying. What do you suggest?
I can't diagnose from so far away. There are rectal pain syndromes that are due to muscle spasms, for example the levator ani syndrome. Massaging those muscles digitally (meaning via a finger in the anus and massagiing them) sometimes helps. If you haven't had sigmoidoscopy, you probably should. CT scan to rule out something pressing on the area is a consideration. It's hard to do much but throw out random ideas from over here....
Hi Sid i believe im dieing from an anal fissure.
Im in deep pain every time i go to the toilet sometimes i get blood sometimes i dont,i have not been able to get any help since i do not have health insurance or money to afford a crs. I been battling this on my own for 9 months and in all seriousness even contemplated suicide.My situation is very serious is has taken a big depressing blow on me, i have lost over 150 lbs do to the fact that im just to scared to eat.Every day on top of my anal pain i get headaches do to my lack of food. What does a person like me do? I have no been able to be employed and get insurance for the same reason,i went to my local county hospital but i did not qualify for asistence.Its just a sad situation and although i have faith the Lord will see me threw what if it just takes a bit of nitro to end this hell.
thanks daniel g.
daniel g: I really have no suggestion other than that you need to see a doctor. Your case is a good example of why our health care system needs fixing. But there's no alternative at this point to being evaluated by a doctor.
Hello,
I had to endure the pain and embarrasement of anal fissures for years. I consulted different physicians and was lectured on diet,personal hygiene, on how to defacate properly and yes the pros (???)and cons of anal sex. Two surgeries and many years later I was diagnosed with colorectal Crohn's disease.
On a lighter note: I was so happy with my surgeon that upon his rounds the next day, I lifted up my nightgown and asked if he could also do a breast reduction. He replied:" I'm not that kind of surgeon"
Sid, I'm the guy from Germany. You could only throw out suggestions online, but one of the suggestions was "levantor ani", and it was right on the button. I researched it and realized that this explained my symptoms perfectly. I went to my doctor, explained the symptoms and what I thought, and he prescribed me treatment for it. I didn't bother to take the drugs, because as it turns out my symptoms were completely caused by stress, and once I knew about it the horrible pain went away within 2 days! Can you believe it? I wouldn't if it hadn't happened to me.
Anyway, I just wanted to drop you a note to say thanks.
Glad to hear it. Honestly, I was half expecting your note!
I don't have an anal fissure but have history of mild constipation and gas and lately I've been having muscle spasms in the abdominal area whilst trying to deficate. After examination my doctor said I have a very tight anal sphincter which needs to be cut a little to allow easier defication. Does this sound OK? Is there any danger of incontinence afterwards? Any ideas as to why I have this condition? I would be very grateful for a reply!
anonymous: I have a hard time making specific suggestions for a specific case, since I'm so far removed. The idea of cutting the muscle for the symptoms you describe is not something I've heard of, so I'd suggest another opinion. And if it's really decided that your problem is a too tight muscle, I'd consider simple stretching under anesthesia before going to cutting it. But you have to understand that from this far away I really don't know what I'm talking about.
Dr. Schwab. I have a clear liquid discharge from my anal fissure that is sometimes pinkish in color. I had a partial colon removal due to chronic diverticulitis about a year ago, and developed a fissure about three months later that I'm treating with diet and creams. My surgeon can't tell me what the discharge is. Can you help me?
john3: I'm sorry, but without being able to see it I really can't offer anything meaningful. I'd suggest starting with your surgeon again, and specifically saying it concerns you and you need help understanding. If he/she can't satisfy you, then a visit to another surgeon -- maybe a colorectal specialist -- might be a good idea.
In August I was diagnosed with an anal fissure. It was also infected causing me an insane amount of pain. The infection cleared up and so did the fissure after 4 weeks but since then, the fissure has re-torn several times.
The first time was 2 weeks after the initial fissure; I had eaten popcorn and it caused it to retear. I healed by applying wheat germ oil and taking herbal sitz baths.
2 weeks later I saw a CR Surgeon who said that my pressure was fine and that the fissure looked good. He then thumped it really hard, causing it to tear. I spent the next week in severe pain as it healed. This time I applied an ointment with lidocaine and nifedipine and healed in a week. I have been fine for the paste 6 weeks. I am managing stool consistency by taking Miralax 1x a day and Benefiber 3x a day. Nonetheless, after Thanksgiving I unexpectedly retore.
My question: why is this happening? Is my skin just super delicate? It doesn't appear to be a pressure or spasming issue, which seems to make surgery unnecessary.
I am going to a new CR surgeon in two weeks. I can't decide whether or not to let him examine me because I'm scared of tearing. How long does it take for these things to heal?
Nancy: I can't venture much of a guess as to why it's happening, without being able to examine you. I think the idea of another opinion from a CR surgeon is an excellent one; of course you DO need to let him/her examine you. My only comment otherwise is that taking Miralax long-term isn't a great idea; but taking fiber regularly is more than fine! Stimulants like miralax can be "habit-forming," plus if it's making the stool too soft it's defeating one purpose of the fiber, which is regular gentle stretching of the anal muscle, by having stools that are well-formed to be bulky, but moist enough to pass easily.
Dear Sid: I have had severe rectal pain for 4 years. I have been checked out for everything including fissures etc by an ano-colo/rectal surgeon. (and every test too) The only thing she mentioned was that I had a weakness on the left side of the rectal ring. It has been suggested to me that I may have nerve damage there. Do you see any patients like this, and if so, what do you suggest they do? Thanks in advance...
I'm really sorry, because I like to be able to help, but I have no way to add to what you've been told, especially without knowing exactly what was found.
Hi,
I just had the operation, but i dunno why the surgeon ask me to cut the Fibre intact or no fibre at all for the 1st week. He said fibre cause the stool become bulky and might hurt the wound...
i very confused now...
:(
Anton
Anton: there's a big difference between what's required for healing a surgical wound, and what's needed to prevent problems after it's healed. He said it was just for a week, right?
Interesting conversation. :-)
I was just diagnosed with a fissure that my doc described as "old and deep."
I've had hard BMs in the past, some that would make me want to cry, and I remember seeing the blood in the toilet. But today, I'm basically asymptomatic. I've always (last 30 years) had some amount of itching and some amount of blood on the paper, but I'm not in any pain.
I had the doc look because of a fairly new skin tag.
He referred me to a colorectal surgeon to have a look. But if I'm not in pain, does this need surgical attention?
From over here, I'm not in a position to second guess your doctor's recommendation. It's certainly fair for you to ask him to clarify the need if you're hesitant.
Yes, I understand that. I guess my real question is, what are the long-term risks of not addressing a fissure?
I don't even know which "anonymous" I'm addressing any more.... there have been a few, and without some sort of signature at the end -- a name, initials, whatever -- it gets crazy.
Please help. i got my fissure about 15 months ago while i was pregnant , and because of the embarresment i never got it seen untill about a month ago, im in agony constantly, im scared to go to the toilet. i have booked in for the surgery and i am just waiting on a date. i need pain relief now, please give me some suggestions.
Soaking in a warm tub and taking over-the-counter pain medication such as ibuprofen is about the only thing I can suggest, other than contacting whomever it is that you'll be seeing. There are topical ointments that can help, but they need a prescription.
Dr--I have had anal pain since Oct 2007.It occurred while hospitalized for Pancreatitis. Its now 16 months. I was diagnosed with both Levator Ani and Proctalgia Fugax. I have been checked out with colonoscopy, MRI etc. The pain never leaves and it burns and throbs. Pain Management have performed 9 procedures including radio frequency ablation. Nothing lasted so I was given the choice of Botox or Neurostimulation device implanted. Insurance approved Botox. I have no fissures. The botox- 100 units into the puborectalis and levator ani muscles lasted for just two weeks.I was on Fentanyl patch and went off it. Many withdrawal symptoms, but after the pain returned. I was approved for 3 shots within 3 months and need to decide what to do next. I coincidentally have a similar pain issue from my shoulder to my fingertips with multiple areas throbbing. Please email me, or anyone else please that has any info to help me--email:barrysegel@comcast.net
bugato: I hate receiving comments like this, because I'd really like to help and it's frustrating (but much more for you) when I can't. But it sounds like you've had pretty sophisticated care, and there's no way I can add anything useful, so far removed.
I have been suffering from what has been diagnosed as an anal fissure for almost 3 months. It seems to get better a little bit than it just stays the same and i digress i have taken nitroglycerin and 2 other compounds they work a little bit and it seems my body adapts i recently had botox showed improvement for acouple of days now im back to pain. It hurts to due alot of activity like walkin and there in lies the biggest problem i am a package delivery guy and i walk all day so needless to say it doesnt help. It seems like it has gotten worse. THe doctor suggested surgery as the last treatment any suggestions i would appreciate it greatly.
David: I can't really give specific recommendations when I don't have the opportunity to examine and fully to understand. But as a general proposition, I feel that when all other options have failed, surgery is an appropriate option. If you read my post, you know what I think about the operation and its outcome.
have you heard about the anal advancement flap
I've not tried it. To me it seems a more complicated way to achieve the same thing. But I have no experience. Here's one report (note that all healed with sphincterotomy, and some didn't with the flap):
A. F. P. K. Leong1 and F. Seow-Choen1
(1) Department of Colorectal Surgery, Singapore General Hospital, Outram Road, 0316 Singapore, Singapore
Abstract PURPOSE: This study was designed to assess differences between lateral internal anal sphincterotomy and anal advancement flap for chronic anal fissure. METHODS: Forty patients with chronic anal fissure were prospectively studied. Patients randomized to the sphincterotomy group (n=20; median age, 34 (range, 16–61) years) underwent lateral internal anal sphincterotomy. Patients randomized to the flap group (n=20; median age, 32 (range, 20–44) years) had an anal advancement flap. RESULTS: All fissures in the sphincterotomy group healed following surgery compared with three patients that failed to heal in the flap group (P = 0.12). No patient in either group was incontinent to any degree following surgery. Patient satisfaction with surgery was similar in both groups. CONCLUSION: Anal advancement flap is an alternative to lateral sphincterotomy for chronic anal fissure.
After giving birth over a year ago I realized I had pain in the rectum that I'd never experienced. Assuming it was Hemorroids (something I'd never experienced) I tried over the counter methods. This only made it worse sending me to the ER a week after childbirth. I've seen a colon-rectal surgeon, a gastro-enterologist as well as general doctors who all went with the Hemorroid theory and perscribed over the counters and pain meds. The last doc said it was an anal fissure and offered creams and laxatives. It's now been over a year of dealing with it and I still am in extreme pain. I don't know who to ask or what to do. I used to be a very healthy, active 24 year old with regular BM's 3-4 times a day. Now I can't even walk for 15 minutes without stabbing pain in the rectum. Please help.
I have no way of adding much without knowing you. I'll repost what I said to someone else in a comment above:
I can't diagnose from so far away. There are rectal pain syndromes that are due to muscle spasms, for example the levator ani syndrome. Massaging those muscles digitally (meaning via a finger in the anus and massagiing them) sometimes helps. If you haven't had sigmoidoscopy, you probably should. CT scan to rule out something pressing on the area is a consideration. It's hard to do much but throw out random ideas from over here....
Hello, I had the LIS procedure done, and the very next day my semen appeared as though it was 100% blood. This went on for days until antibiotics cleared it up. Any idea what could have caused this, and if permanent damage could have resulted?
I have a hard time putting the two events together. You should mention it to your surgeon.
I have had severe anal pain for 6 months. I first went directly to a rectal surgeon who said I had a fissure and he gave me a prescription for hydrocortisone suppositories and said I would heal in a week - it did not and actually got worse.
I decided to get a second opinion and went to antoher rectal surgeon. This guy said that everything looked fine except I had a red rash around my anus that extended about 1 inch in all directions. He prescribed some sort of cream used to treat priutus ani and told me to use cornstarch from the cooking aisle to keep things dry. This did not make the pain go away either.
I then suffered through the pain for a couple of just praying it would go away. After it did not and got even worse I found that I could also see a gastroenterolist (I had to drive an hour and a half to see a rectal surgeon as there are none in my area). So I decided to go see them. They again said that I had a fissure and prescribed the hydrocortisone suppositories again. After this did not work (again) he moved on to Nifiedipine/Lido suppositories. These burned very much when i used them but he said to suffer through so I did, but they did not help the pain either. He was also very mean to me and wouldn't return my phone calls for days on end after asking me to call him if things did not improve.
I then had a bout of colitus for a week or so and had to switch my high fiber diet to a low fiber diet - basically I ate just mashed potatos for a week.
I then went to my primary care and she gave me prescription for nitroglycerine cream and more of the Nifiedipine/Lido suppositories to use together.
The pain hurts so much I want to scream - I can't concentrate on my work, I can't sleep at night, and I've found myself getting very grumpy and being mean to my spouse because I'm in constant pain 24 hours a day with no relief for six months now.
Is there no way to relieve the pain immediately, like an injection of morphine or something? I'm absolutely miserable and want to die.
Robert: I wish there were something I could do, but there really isn't, since I have no way to evaluate or treat you directly. I think you need to see one of the surgeons again.
I went back to the gastroenterolist that I don't like again (he is the only person that could see me for next two weeks) because I've developed a red rash that surrounds my anus about 1" out, and then extends up the ridge of skin between the anus and the scrotum. He is sending me to a surgeon but I have to wait until monday to see them. He didn't have any advice for what I should do about the rash so I've been putting neosporin on it as that was my best guess as to what i should do. Now not only do I have the horrible stinging pain from the fissure, but I have itchiness from the rash as well. I tried the Nitro cream once a couple of days ago and it felt like I was placing fire directly on my anus, I washed it off after about 10 seconds of the horrible burning. I'm not sure if it was burning because of the rash or if it is supposed to burn like that. Anyway, it also gave me an instant pounding headache. I'm picking up some more of the Nifedepine suppositories tonight to use until I see the surgeon next monday, but I'm afraid that it's going to hurt like hell to use them and it will be for nothing.
Robert,
I am NOT a physician, however I do have anal issues - fissures, and hemorrhoids. You might try Balenol - this is a cleansing product for the anal area. I found it at a well known retail/pharmacy store.
Good luck!!
Sid, how long is the recovery for LIS? I tried to read through the posts to find that information, but was unsuccessful. Thanks! - Melissa
Melissa: for nearly all of my patients the pain relief was immediate, as soon as the operation was over. The fissure and/or (depending on how it's done) the surgical incision may take a few weeks to be fully healed, but the pain typically goes away right away.
Thanks, Sid! I have an appointment with my dr next week, so I should know if surgery is the way I have to go. - Melissa
I am a 39 year old male in Cali. I have been fighting with this diagnosed anal fissure for two years. I have been using the nitro salve when I feel pain. The pain will kill me for about a week and then subside.I can't stand this anymore I feel my life has been put on hold due to this condition. I am so embarassed by this I can;t stand it. I don't know what else to do. I read you article and I feel exeactly like you described. I just want out of this pain.
justaguy: seems like you need to see a surgeon to discuss your options.
I recently had the surgery and i dont feel the pain some times i still feel a slight discomfort periodically out the day one day it was an itch i wanna know is this normal in the healing process and today i saw slight blood again first time in 5 days i saw blood. surgery was 10 days ago. Also should i use ointments to help healing
david: the best person to answer your questions is the one who did the surgery.
Love this blog! Made me laugh while trying to forget the pain I was in. I've been in pain for a couple of months, and finally three weeks ago (after two docs suggested hemorrhoids), was diagnosed with an anal fissure. The pain is horrendous, and it scares me that a few people here have said they have reoccurring fissures. I hope mine's a one-time deal. My surgeon first prescribed nifed, lidocaine jelly, miralax & suppositories, warm baths and/or ice (in the finger of a latex glove if that would help--it didn't). NOTHING made a dent in the pain. Switched to nitro. Sometimes I don't have pain until I use the nifed or nitro, then I start having spasms. The past week or so, it seems that the pain is going away more quickly, but then I've also been taking ibuprofen and vicodin for when it's really bad. (Also have valium, but only take it when I'm at home, and have only had to take it twice). We discussed Botox and surgery. I was put off by the surgery, but your description made me think maybe I could handle that. But the one comment about fecal seepage the size of a baseball...Yikes. I'm 45, and have had bowel problems since I was a child. I'd been going along pretty well this last year, putting Benefiber in my coffee, trying to get more fiber in my diet. Heh...I only wanted to see female doctors, but one day I was in tears while calling for an appt., and broke down and said a male doctor was ok. I can't imagine having this on a regular basis, and I'm going to do my best to make sure this doesn't happen again. Thanks!
vonnie: putting benefiber in coffee. That's commitment!
It's amazing to me how frequently some doctors think such pain can be due to hemorrhoids. Glad you got the right diagnosis, at least. And since you still have the options of botox and surgery, it seems eventually, one way or another, you'll get there. Good luck.
Anonymous
Hells Bells!
This is not funny anymore. Three months ago I was happy person, walking 10km a day and losing weight voluntary. Now me arse is on fire, I go to bed with a wet tampon up my crack and passing what feels like broken glass. I am very grateful if bowel movement prove to be only wind and to give my ring gear some rest, I am not eating for days.
Gone are the carefree days when sitting on the toilet meant relief and to generally contemplate one's excistence and importance on this planet.
Now every visit to the bathroom is carefully planned, even days beforehand and courage are scraped from somewhere near the bottom of the barrel to do what comes next.
Beastly things, I say.
Lubricating with KY jelly that organ, which I hitherto took for granted and was deemed socially inappropiate to even mention, holds no more secrets from my probing finger. I now know its design and amazing constuction intimately.
I've wondered often what I have done to deserve this, for I never had any plans to become so familiar with its internal structure or intruding presence.
Losing weight is'nt a problem anymore and if this continue as it seems likely to, I might soon even fit in my school uniform again.
Furthermore, my typing skills have improved because of the many hours I've spend on the internet since sleeping is sometimes impossible on none toilet days.
Heck, if someone says that they will do anything to lose weight I would suggest swallowing a golfball. That should do the trick because one small tear in your anus is all whats needed. The rest will happen by itself. All the willpower needed to stay on a diet will be magically replaced by a strong resisting force from somewhere in your being that you never thought existed will make you think twice about every mouthful you take.
Things that help me are:
~ lubricating the anal canal with jelly before deficating to assist passage of faeces
~ not to put any ointment/prescribed drug on or inside for about 6 hours after deficating. The anus goes in spasm after deficating and it does not only hurt very much trying to force anything inside, it burns also like hell. Only after about 6 hours or so do I feel comfortable enough to insert anything or in the morning.
~ time of going to the toilet. I usually leave it to after dinnertime and drink 4 strong prescribed painkillers immediately afterwards. I have found that the pills start working after half an hour, about the time that the anus seriously contracts into a spasm. Also putting a soggy wet tampon against the anus gives immediate relief. I have found that trick after showering once with cool water which I channeled into my crack. I very well could'nt shower all night but repeatedly using a wet tampon helped a lot. Because it is a rather wet operation, it is best to do it before bedtime, thus the time to deficate becomes very limited. With the help of the sleeping pills and a cool bum, I often fall asleep easily and the next morning feel almost new.
~ I eat as little as possible for two days, using laxatives to aid a runny tummy and would only eat more on the third day and go to toilet that evening. I walk as little as possible the next day.
Normally by the second day I feel like I never had any problem. So I have limited the bad days to one every 3 days.
The doctor probably wont agree on many of these points, especially the pain pills but I use them only every third day.
Three months ago I would not have been caught dead trying to give advice about such a grous subject but pain like this I never knew existed.
Right now it is 04:00 in the morning and havent had any sleep because I deviated from my program and ate too much the day before.
Ahh, the joys of life. It is sooo much more complicted with a nice old fissure.
I think its time to wet the tampon again.
Anonymous: great thanks for your amusing and well-written post. I'd say it deserves a wider audience. As to your remedies, whatever works is okay, I'd guess; but, as you predicted, I'm not enthusiastic about it all. Starving oneself. Going from constipated to medically induced liquidity: the perfect way to keep the problem going forever.
I infer you've seen a doctor, and have so far rejected the more definitive options. Your choice, of course. But there are ways to stop the cycle and start the healing, with a high probability of success. Meanwhile, I'll not tamp on your tampon.
I have an anal fissure diagnosed by a good colorectal surgeon. He has me on 6 weeks of a Hydrocortisone Acetate 2.5% - Pramoxine HC! 1% Cream. I have a soft stool 1-2 x per day. I am in great pain after BM, a spasm so intense my pelvice floor muscles are involved. Do you think this cream is wrth the wait and torture?
mir: in my experience, hydrocortisone cream doesn't do much. I don't want to second guess a colorectal surgeon, but it surprises me that that's what was prescribed. Maybe there's something else going on. For fissures, there are other creams that might do more, such as nifedipine or nitroglycerin.
The horror of anal pain! It's been 7.5 months since the most awful surgery of my life- a two quadrant hemorrhoidectomy. After a month of spraying blood, fever, night sweats and fear of impending doom, I went in and of course... the left side was infected. Sutures were removed and I was left with a delightful open wound that STILL has not healed. Now it's been described as a fissure/ulcerated area of hellish pain and agony. What to do? I have used nifedipine ointment, had two rounds of botox with some incontinence as a side effect for an added dose of self-esteem. And I'm nowhere even close to resolution. The pain is immense and at times all-consuming. I've got scar tissue from the hemorrhoidectomy on the right, the fissure ripping apart on the left, and I am seriously losing my mind. My ass looks like someone hacked at it with a machete. I found this website last night during one of my many late night searches for a miracle cure and got a good and much needed laugh... at least my sense of humor hasn't been completely destroyed. I'm on bucket loads of Neurontin and Valium, stick a Fentanyl patch on at the worst times, have gotten caudal blocks at a pain clinic and have seen multiple colorectal surgeons for their opinions. I can't wrap my head around the fact that the doctor who performed this hemorrhoidectomy- the cause of my continued and constant suffering- said he did the left side too "because I was there"... there wasn't anything wrong with it- but there sure is now!! I don't know how I'm going to get through this, but I have to believe that there is someone skilled enough out there who will be able to sort this out and get the wounds to heal. I already had a sphincterotomy when I was young and I do not want a repeat of that surgery. So... in the mean time I will continue to live most of my life partially submerged in the tub and praying to God for relief! Oh the humanity!
I was just diagnosed with a fissue 4 weeks ago.This was caused by horrible diahhrea I had after being placed on Augmentin for an abcess after I had my wisdom teeth removed. My colo-rectal dr basically sent me home with the instructions of taking lots of stool softeners, eating lots of fiber, and 3 -4 sitz baths a day. He told me to come back in 8 weeks and if it wasn't at least 50% healed, he'd schedule surgery.
After 2 weeks of excruciating pain, someone suggested I get Lidocaine gel to help. I called my Dr and he gace me the Rx for it and it helps so much with the pain I was suffering from after bowel movements! I can't believe he didn't give it to me in the first place!!!
But he problem still lies with going! My pain is still excruciating when I go! No better, after all the diet changes, and some days actually worse, to the point where I cannot even relax enough to go d/t the pain!
I've been doing research and called my dr back to see if we could try GTN, or even Calcium blockers such as Nifedipine or Diltiazem, as it seems some people have success with these, and less invasive than surgery.
I was told NO. Just keep up the home treatment and it'll "get better". I'm in so much pain and not sure why my dr is not wanting to try these things if the home care isn't working!
Should I get a second opinion?
A second opinion sounds like a reasonable idea.
Do you typically see good results from the use of GTN or any of the calcium blockers? IS there anything you think typically works better than others? It seems like from my research that the Diltiazem gets about the same results w/less sie effects.
If by GTN you mean nitroglycerin (usually abbreviated NTG), yes it can help. So can botox, as well as the Ca channel blockers. In some people one works better than another. I have no basis for a particular recommendation, nor would I make one for an individual not in my care.
I just wanted to report that I am finally starting to feel better. I took the advice I saw on here about cutting apples out ( I was eating one a day) and I think that has helped! I also took the advice on finding a different way to sit on the toilet when you have to "go" and that has helped also. Can't say enough about the relief I've gotten from the Lidocaine Gel. Didn't help with the going...but after it makes life livable...no more hobbling around! I'm still thinking about getting a second opinion to try some of the CA blockers, but I'm starting to think that the home treatment - lots of stool softeners, high fiber, and lots of sitz baths - is finally working. It has been 5 weeks now, and that has seemed like a lifetime, but I no longer am in total fear of "going". It's still painful, but no where near what it has been!!!
I'm glad I found this site!!! It's nice to know I'm not alone out there!!! I think for some one who hasn't experienced this, there's no way they can even relate to or imagine the pain and agony!!!!
I had my surgery about 5 weeks ago with a basic local anesthetic, I refused to be put out for such a short length surgery, it was not that bad, but now I have noticed that I'm getting some pain down there like it has ripped again. I'm still on high fiber diet and sitz baths but now I'm worried if it will get better and or is it common for a rip to occur after surgery but yet heal?
Thanks
Louie: recovery isn't always a perfectly straight line, but the best advice I can give is to check back with the doctor who did the surgery.
Hello, I just read one of the posts about bloody semen the day after the surgery. I about fell out of my chair. That is exactly what happened to me. My semen looked like 100% blood. Went back to my surgeon. He gave me antibiotics which helped after a few days. Obviously, there was damage done to my prostate during the procedure. Considering I have had horrible fecal leakage ever since the surgery, I wouldn't doubt it if my prostate was cut w/a scalpal! I think the surgeon must have sneezed while the scalpal was up my ass! That sneeze put in me in a permanent depression which has lasted for the past 10 years. As a surgeon Sid, I'm sure you have ideas of what errors can happen during the LIS to cause bloody semen, and surely you know what can cause severe, permanent fecal leakage. How about making an incision that isn't quite correct (scarring issue), cutting too much internal sphincter muscle, or even cutting the external sphincter muscle. I'm sure there are other things I'm not mentioning here. Would you agree that things things can happen and could cause continence issues?
Incontinence is a known complication of sphincterotomy. It's pretty uncommon (if it weren't, the operation wouldn't be done!), and it doesn't necessarily imply an error was made.
Since the cut is made at the opposite side of the ano-rectum from where the prostate is, there's practically no way the cut itself would have anything to do with bloody semen. It could be related to how a retractor was used to expose the area, I suppose. Until now, I'd never heard of it as relates to sphincterotomy.
Hello,
My roommate has recently been diagnosed with an anal fissure. He has spent over a week in the hospital and they have recommended surgery, however he has no insurance and he does not qualify for county or state coverage. I am worried for him because he is in a great amount of pain on a daily basis. He has been taking stool softners, high fiber diet and supplements, sitz baths, everything that has been recommended other than surgery. I am also concerned because he feels as though he is unable to work due to the pain and suffering he is constantly going through. I guess I am just looking for advice from someone so I can better understand his situation. Thanks.
Unfortunately, it's impossible for me to comment meaningfully on a situation about which I know nothing, other than to say it's really unusual to be hospitalized for a week with a fissure. The cost of that alone is way higher than the surgery to fix it, assuming that's all the problem is.
Incontinence may be a known complication of LIS, but it was not even mentioned to me prior to my LIS 10 yrs ago. I was told there might be some "leakage" post-surgery, "but it should stop within a few weeks." I thought the "leakage" was a reference to bleeding. Next thing I know there was leakage the size of a baseball on the TP within 30 minutes or so after each bm. Sometimes this occurred several times after each bm. My surgeon's first explanation was I wasn't "wiping good enough!" Then it was "give it time." After a couple of months, I was told that I had suddenly developed internal hemorrhoids that must be causing the leakage. After many visits of getting these mysterious hemorrhoids (about a dozen) removed via rubber band ligation, I decided I was not benefiting in the least by seeing this surgeon. I went for another opinion. After the finger probe the next doc immediately tells me "too much muscle was cut," and then asked how old the surgeon was who did the procedure. Isn't that an interesting question? He then said there was nothing he could do for me. Note this surgeon saw zero signs of any hemorrhoids. I went to another colo-rectal surgeon who told me I had developed a keyhole deformity and that there was nothing he could do. Interesting how a keyhole deformity can develop from an LIS??? Note this surgeon saw zero signs of hemorrhoids. I finally found another surgeon who decided to attempt a sphincteroplasty. Note this surgeon saw zero signs of hemorrhoids. Anyway, the surgery was done, and the surgeon told me there was a "very large gap" to close. This surgery helped me significantly, reducing the leakage on the TP to maybe the size of a golf ball (very good compared to baseball size), but still a problem. I was and still am very grateful to this surgeon for believing my claims of serious leakage. However, when I asked for specifics of how much muscle was cut from the sphincterotomy, this surgeon would not give me an answer. My strong assumption here is that avoidance of my question means something very wrong was done during the sphincterotomy. It’s not right to keep this info from me, as I have the right to know. I’m sick of all the secrecy I’ve encountered over the years from the many colo-rectal surgeons I’ve seen. If you know what the problem is, for God’s sake tell me. It’s pathetic! Have some nuts and be honest. I’m posting this info not as a question to Sid (I’d get no direct answer anyway), but to inform people out there considering LIS, like anything else, mistakes can and “do” happen – resulting in permanent problems. Incontinence is not something you want to have in your life. It’s emotionally draining to say the least, particularly for a young person. I was 29 when this started. Do everything you can to avoid a scalpel near your ass! If you think I sound like a bitter person, you are exactly right. Good luck to all of you suffering from a pain in the rear.
i just came across this page. not sure if you reply anymore but i'll still try my luck. I'm female in my mid twenties, asian, with rectal bleeding on and off for the past 2 years. Was diagnosed with anal fissure about 4 months ago (though i never did go for any colonoscopy at all) by a specialist. The strange thing was that for the last 2-3 months, i've been having rectal bleeding almost every other day! I went to see another younger specialist doctor last week and I told him about it. After peering at the region, he concluded that there was an anal fissure on the right side. I told him that anal fissures on lateral side could point towards other underlying conditions, but he dismissed my concerns, saying that it was nothing serious. I'm worried though! what do you think?
You don't describe the bleeding (how much, only with stools, etc), but I'll give some general comments.
The hallmark of fissures is pain. They usually don't bleed very much, maybe a little streak. They are pretty rare in any location but the midline.
The most common cause of bright red bleeding in a young person is hemorrhoids, particularly if it's painless and enough to redden the water or bleeding spontaneously. It can be a mistake, though, at least in my opinion, to assume that's what it is without at least having an anoscope or sigmoidoscope inserted.
I've seen a couple of young women with rectal bleeding due to endometriosis, but that usually occurs with one's period.
I can't diagnose you from far away, but I hope the information is helpful.
It's great to see this post has kept people talking for years!!! But I didn't see anything relating to my problem as a gay man diagnosed with a chronic anal fissure. I have lived with it for about 3+ years and I haven't been able to enjoy sex this whole time. I'm only 28 and not thrilled about the LIS procedure and the effects it may have on my sex life as a receptive participant in anal sex. I'm leaning toward the BOTOX procedure to see if it will heal. My concern: IF the fissure heals once and for all..is it safe to say that it's gone for good? I have this fear that the scar tissue isn't as "stretchy" as the normal "skin" and I will have to give up anal sex alltogether. I'm afraid that once it heals..I just keep ripping it again in the same exact spot every time I try to have sex. Is that possible? I just want to be able to have sex again. Does the LIS procedure drastically reduce the "tightness" of the sphincter? It's an option I will have to consider if the BOTOX doesn't work. Any info would be greatly appreciated.
Matt B.
Matt: As you'd expect from any doctor, I'd guess, I have to say there are no guarantees. Anal sex or not, no healing of a fissure, by whatever means, is necessarily forever.
LIS has a slight -- quite low -- risk of incontinence problems. For the vast majority, it leads to healing and normal sphincter function. But it makes sense to try non-surgical methods first. Because the effect is temporary, Botox ought to have no long-term effects.
Once healed, it ought to be possible to resume anal sex; gentle dilatation and generous lubrication are essential.
Yours is a good question, and I wish I had more to add. Maybe Dan Savage would be a resource.
I have been fighting an anal fissure for 3 months. This fissure seems to have been preceded by a marble sized "something" that pops out of the anus during a bowel movement. As if the fissure isn't painful enough, pushing this thing back in nearly makes me faint.I can't get an answer as to what this may be. The next procedure for the fissure that we are going to try is Botox, but what good will this do if this thing keeps popping out and ripping me open?
It's not uncommon for there to be a "hypertrophied papilla" at the apex of a fissure. Essentially, it's a benign fibrous growth. Occasionally they can be large enough to pop in and out of the anus. It ought to be very easy to find out for sure by having an exam by place a small scope in the anus, and if it hasn't been done, it ought to be, in order to be sure what it is. They're simple and painless to remove.
Sid, I am a 47 y.o. female nurse and I have had a problem with hemorrhoids (not fissure) for years. Last December I found out I had a carcinoid tumor and had right hemicolectomy. After surgery I took stool softeners but still had to strain for BM even though my stool was soft. Then I developed another hemorrhoid problem this time diagnosed with anal fissure as well. Treated with NTG cream - hemorrhoid and pain returned. Underwent total hemorrhoidectomy / anal dialtion. Have had chronic PIA since March 2009. 1. Could the hemicolectomy have damaged some nerves as I had to strain to have soft BM's post op? 2. What to do next? As a nurse, I can not bear this pain daily at work. Also, I used to run 20-30 miles per week and now am a couch potato because I just do not feel like it. HELP!
I can think of no relevant nerve pathways that would be affected by a right colectomy. Left, or sigmoid: maybe. All I can suggest is getting another opinion by a colorectal surgeon.
Thanks for your response. I failed to mention that the colorectal surgeon I saw did a digital and anoscope exam (without sedation or warning of the pain). He diagnosed the fissure. Long story short, I did not trust him for follow up and ended up with a general surgeon I knew and trusted. He told me after the hemorroidectomy all would be well. I did not know that anal dilation was not recommended anymore. Needless to say I am a little scared of letting anyone near my backside. I have been on stool softeners, high fiber diet, increased H2O intake and warm baths for months. Somehow I knew you would suggest a second opinion from a colorectal surgeon. I am just scared of the pain. What I endure daily is about all I can take. I don't know how I could get thru the exam.
There are times when it's indicated to do the exam under anesthesia.
Well i'm scheduled for LIS August 5th and honestly i'm a little freaked out. I've had my fissure since December, so 8 months now. I appeared after a procedure in November to remove warts from inside my anus (how many I don't know). I think I have a grade 3 internal hemmorhoid (I have to push it back in after a BM...talk about painful with a fissure). The surgeon doesn't seem too concerned about it. Will the hemmorhoid interfere with the healing process of the fissure? It prolapses during every BM and when pushing it back in the pain is awful. Unfortunately I don't have insurance and a family member is paying for the LIS...but i'm really worried this hemmorhoid is going to screw up the recovery. Any thoughts?
Hemorrhoidal banding is simple and effective, and, if the anatomy is right, generally painless. It can be done along with LIS under the right circumstances -- about which I have no way of knowing in a specific distant case. You could ask your surgeon if it'd be appropriate. It might or might not be.
Thanks for your thoughts. So the prevailing opinion is the hemmorhoid will not interfere with the fissure healing post-op? It's just going to be a real pain in the butt (literally) pushing it back in after a BM for a couple weeks.
I have had an anal fissure now about four months and am currently seeing a colon rectal surgeon. He prescribed diltiazem and it seems to work ok at preventing my bottom from tightening up. I use vaseline with before every bowel motion and sometimes it helps other time it doesn't. My problem seemed to be getting better for a while - little to no pain with bowel motions almost normal. Two weeks ago I had a set back and now experiencing similar pain as I was earlier. I also now have some pain and bleeding with bowel motions on the "outside" area or the anus, feels very similar to a fissure. My fissure is located posteriorly closest to genital area while my new bleeding area seems to on the other end. I am seeing the surgeon again in about a week but found your blog and thought I could get your thoughts. Hope this is alright and I appreciate anything you can offer. Should I consider surgery? I eat a vegetarian diet now with lots of fruits and drink plenty of water. Also take a stool softener. I use qtips (is this a problem) for applying the creams to my anus. Thank you and this is a very informative blog.
I don't see a problem using q-tips gently. I'm not really in a position to comment on your options, not knowing enough about the situation. As you already seem to know, it's important to have enough fiber in your diet to have bulky but moist stools which are easy to pass.
Thanks for the feedback. I was wondering in general if after a set back surgery might be considered ~ I personally am leaning more towards it but will await the advice of my surgeon. I can totally relate to the cure or death feeling everytime I have a number two. I just was generally curious as to when it gets considered since my family doctor told me that it was for very remote cases that surgery was used so that is why I wasn't sure.
Dr. Schwab,
Wondering what your thoughts on Miralax are to get the correct stool consistency for anal fissure healing. I have posted before. I am the one who had a right hemicolectomy, hemorroiddectomy, and anal dilatation. Have been dealing with this for 6 months now and I can't get stools right to help the fissure heal. Too loose, or too firm. I have literally tried everything and am currently having liquid stools with the miralax, 3 doses of benefiber, fiber one cereal and light dinner. Do you have a magic RX for combination to get the soft (toothepaste consistency) stool? I think that due to my hemicolectomy it may be causing me trouble getting the right combo. On the verge of having to see another surgeon, but if I could do anything to avoid more surgery, I would prefer that.
Thanks, Neena
Neena, I don't think of Miralax as a long term solution, nor do I agree that "toothpaste" is the ideal consistency for long term management or prevention. You need more bulk than that, while still having enough moisture that it's easy to pass.
In the short run, though, it can be necessary to have softer stools for healing. The problem is that I can't really make specific recommendations without knowing for sure what's going on, what it looks like, etc. So I'd say you really ought to have someone looking at it and making recommendations based on a face to face (as it were) exam.
Thanks, Dr. Schwab,
Will call my CRS tomorrow for appt. Will definitely ask to schedule exam under sedation, but if he won't comply, have a GI doc that will do sigmoidoscopy with sedation on standby.
Neena
I had a baby in March 2009, via C-section. They gave me morphine and dilaudid, in which I had an uncomfortable reaction to both. I ended up toughing out the pain (no big deal) until I healed. Meanwhile, I developed a fissure. Now, I am a 4x-a-day pooper, I am proud to say, and so after the morphine, I couldn't go at all. I thought I was going to die with just that, but when the fissure arrived, I thought it was REALLY over. Of course, my doc gave me steroid suppositories (People! These do not work! Don't go there! You'll just suffer longer, especially if you have a chronic fissure). They burned and made the pain worse. I couldn't even nurse my baby because of it. So, after a little homeopathic research, I came to a conclusion: the sphincter needs to be relaxed from its contractions, plus, the tear needs to heal. So, I mixed a concoction of equal parts of olive oil and honey (you only need a TBSP of each to make a batch), and with a washed finger (no nails please...use a rubber glove if you have to), I inserted a small amount into the anus and used my finger to stretch the muscle ever so gently, back and forth, side to side. I know this sounds weird, but God puts things on the earth to help us, espcially if we cannot get to the doc. Honey has a healing effect on soft tissue wounds. You have to repeat this process before and after you poop. Wash your hands after you do it (DUH!). Wipe off any excess that is between your cheeks, and place a small piece of TP against your anus in case there is some leakage. And, Ladies, be sure you don't get the mix near your "other place;" you might get an infection bc of the sugar. It might not heal your fissure completely, but you will have relief and a good lube job until you can get surgery or another treatment. Happy healing!
HI, me again! YES, eat your fiber, like Dr. Schwab says. It's not brain surgery. You need a good amount every day to get your bowels moving properly. OTC fibers are mediocre to what is in your grocer's produce department. So what if you fart a lot when eating fiber. Do that when you are alone and practice your Kegel exercises regularly! Here's something I made yesterday, and WOW! Did it do the trick!
Sautee in 2 TBSP safflower oil: one large choped-up ONION, one stalk of diced CELERY, one diced POTATO...cook until semi-soft. Add 3 cups WATER and bring to simmer. Add 2 cups pre-soaked LENTILS or SPLIT PEAS and a cup of chopped, fresh or frozen OKRA. Add one TBSP of CURRY POWDER for taste. Add some SALT to taste. Stir occasionally to prevent burning. Cook until water is cooked down to mere nothing. Serve over brown or basmati rice. Sounds weird...tastes FABULOUS!! And your bowels will thank you!
T-i-l-i-i: pretty good advice. Of the honey/olive oil, I'd propose the most important thing is the stretching of the sphincter which, as I believe I wrote, is one of the "surgical" treatments of fissure. I absolutely agree steroid suppositories don't work and it's too bad they're still used.
I just deleted a comment which is no longer seen in any way. This blog is not a place for people to hype their businesses.
You know who you are. Go away.
Hi Doc - I am going to have a spincteroplasty for a 140 degree tear in my sphincter. What can I expect in terms of recovery? I don't see my surgeon for a few weeks and unable to find info on-line about this. Thanks for the blog!
Tracy in CA
Tracy, it's hard to say anything very specific without knowing the anatomy and what will be done to fix it.
Here's an article that suggests the wide range of options.
Although I'd guess your surgeon would have the same problem saying much without seeing you, you might consider calling his/her office and asking if there are any handouts or other information available in advance of the appointment.
Dr. Schwab,
I was reading T.I.L.I.I. post about the honey and olive oil. I have heard of lubrication pre and post BM and the benefits of dilatation, but was concerned about the use of honey and olive oil. Well, more concerned about the honey. What are your thoughts on the use of those particular lubricants?
Thanks,
Neena
Until that comment, I'd never heard of it. No basis for opining, other than to think it'd be pretty messy, and one would want to avoid applying it near an ant hill.
I have been feeling a lot of pain in my ass after I use the restroom. After I use it I get a lump in my ass about the size of a finger nail and it hurts like hell. I can't sit or even lay down. Before I knew how big it was i use my finger and felt in my ass. This has been going on for about 2 months now and I can't take it any more. I'm wonder do u have any suggestion or should I just go see a doctor.
Hi,
This is Sid's wife. Sid is away from his blog, and will get back to you when he returns on Saturday.
Anonymous: yes, I'd say you should see a doctor, because it's impossible to know exactly what's going on without seeing it. Fissure is certainly high on the list of possibilities, but you really can't diagnose or recommend treatment without having a look.
I first wrote to you on July 31st to get your opinion on "something" that pops out of the anus during a bowel movement. Your thought that this was a papilla was correct and I am happy to report that after a sphincterotomy and removal of the papilla, I feel great! I suppose that when my colorectal surgeon chose his specialty in med school, repairing fissures was not what he had in mind. But this surgery literally saved my life.
Hi Sid,
I am a physician who has suffered with a chronic anal fissure. I tried NTG, Miralax and Proctosol initially, and had a full colonoscopy, all recommended by a GI. The fissure improved, but did not heal. A colorectal surgeon performed a partial LIS a excision of a pile. The fissure healed, there were no dreaded complications like involuntary flatus or soiling, and I live on Metamucil and a high-fiber diet. However, the sphincterotomy site feels "full" and there is a visible "fullness" at the site of the sphinterotomy where the divided muscle has retracted. This feeling is bothersome when I stand, bothersome when I sit, and gets worse as the day progresses. The only time it really feels okay is when I wake up. Have you ever heard a story like this? The studies talk about satisfaction with LIS in very limited terms with respect to outcome, but thus far LIS has not improved my life. My surgeon says it may improve over a period of years, and may even look normal. Any thoughts?
Jason: not sure what to make of it, and can't recall any similar complaints. It sounds like the LIS did improve your life, assuming the fissure had been as painful as they typically are.
If the fullness isn't tender then some sort of chronic infection seems unlikely, but I suppose it's a consideration. Being unable physically to assess it, I can only suggest either a revisit with your surgeon, or with another for another opinion. Not sure what "partial" LIS means
Hi Sid
I appreciate your response. I thought I should follow-up with a few points to clarify.
1) The original medical therapy prescribed by the gatroenterologist improved the fissure to the point that it was not painful, it was not bleeding, and I was fully functional. However, the NTG gave me a headache, and the fissure would annoy me when I sat in the car. I also started slouching, which created other issues. The colorectal surgeon noted that the fissure was small, that it was still there, and that it was horizontal, not vertical.
2) Partial LIS means that the division of the IS went to the dentate line. I had actually told him to do a "tailored" LIS, ie no further that the level of the upper pole of the fissure. He felt that was not adequate.
3) The fissure healed, but I am sympomatic in different ways. I would not say my life is improved. For example, I took a short airplane ride, and could not find a confortable position in which to sit. I dread every car ride and every flight I must take. Also, despite the lack of any pain associated with the bowel movement, two days ago, there was bright red blood on the wipe (not toilet paper, I gave that up).
Yes, I am going to see someone else. The fact that I wrote to you is itself an act of desperation. Clearly, you spend a lot of time on this site, and I am sure you are helping a lot of people. I appreciate the time you took to answer my inquiry. Personally, I do not believe I have an infection. I think by all yardsticks currently used, my case would be considered a "success". However, sometimes the personality of a patient is important. I am extremely obsessive, and it makes me good at what I do (I recently got a touching note from a patient thanking me for saving her life). I am well regarded, with many academic credentials, and a long list of publications. I have a loving family, and anyone looking at me would think I am extremely lucky (You probably suspect that my name is not Jason. It is not, but I am too embarrassed to be open about much of this). Yet, I could not be more miserable and unhappy. How ironic!
LIS Testimonial here. I had a fissure develop December 2008. I suffered with it until August 4, 2009. August 5th I had a lateral sphincterotomy. 1st week post-op: No pain during BM but wicked burning and blood (jumped in bathtub pain gone in a minute). 2nd week post-op: blood but less of it, and minor pain during BM. 3rd week post-op: continued lessening of blood and minor pain receeding. 4th week post-op: tiny tiny amounts of blood and no pain. The incision site did remain wicked sore to tender up until about three weeks ago. As of today i'm blood and pain free and my surgeon says i'm healing beautifully. I have my life back (though I haven't yet started lifting weights again). I'm really digging the high fiber diet and rather than depending on fiber supplements I eat a couple pears and a couple peaches a day along with high fiber oatmeal at breakfast. Then I try to get 5-8 grams at lunch and another 5 at dinner. Oh and about 55-60oz of water a day. From March to August I lost about 12lbs due to lack of eating and now i've regained about 5 of those. I've also eliminated caffeine entirely from my diet.
Thanks for commenting. Glad you're doing well.
Sid-I happened to come across your blog and I truly appreciate your humor. It was like a breath of fresh air to read your blog and the comments. I am so sick of the cookie cutter info out there. I hope you can help me Sid-I have had some HORRIFIC experience so far with doctors and clinics that claim to "specialize" in hemorrhoids. They all have also seemed to have forgotten how to "specialize" in patient care. Long story short, I have had several doctors tell me all sorts of fun things and even had the opportunity to have a thrombosed hemorrhoid removed (while awake) by an "on call" surgeon who specialized in breast cancer. All along, it was this pesky fissure causing all this pain. Unfortunately, it took about 5 painful doctor visits until it was discovered. I have tried just about everything to get this thing to heal *SIGH* but it lingers on. Jello, fiber, lidocaine, vaseline, sitz baths, ice, water, special yogurt....more water...witch hazel... I have also tried to avoid further treatment at all costs (I am SCARED Sid), but can't put it off any longer. While I can think of several things that would be less painful than going to the bathroom every day-dipping my body in honey and rolling around on a fire ant hill, getting a tattoo on my skull, walking through molten hot lava....I simply cannot stand it anymore. I feel that I am at the mercy of these crappy doctors and the one "specialist" clinic in my area. Can you recommend any good docs in San Diego? Who should I look for? HELP ME SID!! Pleeeeaasseee!
Daisy, I have no specific knowledge of docs in the San Diego area. All I can suggest is that you see a colorectal surgeon. I'd say that many clinics that "specialize" in hemorrhoids aren't made up of colorectal surgeons, and that a board certified one ought to be able to recommend and carry out appropriate treatment.
geez where to start... i am a new mother and during the course of childbirth (in April) i developed a large haemorrhoid. The haemorrhoid shrank but then i was getting extreme pain during and after a BM, my doctor diagnosed an anal fissure and the original haemorrhoid had changed to a skin tag at the bottom of the fissure. I have been using Proctosedyl to manage pain and Coloxyl to assist healing (by soft stools). I have had no significant inprovement although some days/weeks are better than others. My doctor can see no sign of healing occuring. I more recently stopped using the Proctosedyl for fear this may be limiting healing (but pain has increased ten fold). I do not want to use creams as i would be required to stop breastfeeding. My question is how long should i nurse it along in an attempt to heal without surgery? At what stage can i assume surgery is my only answer?
anonymous: (congrats on the new baby!)
I'm not sure which creams would require you to stop nursing. Before turning to surgery, options include nitroglycerin and botox, neither of which would strike me as requiring cessation of nursing (but I admit to not knowing with certainty.) There's another cream, too, diltiazem, which, I suppose, might.
When to opt for surgery? When you've had enough, I guess. It is generally done as an outpatient procedure, and, with an experienced doc, can even be done under local anesthesia. It's generally done under general or spinal, however (general is preferred because the procedure takes only a minute, and recovery from spinal can take a few hours.) It's usually recommended that women stop nursing and pump breasts for 12 - 24 hours after general anesthesia. Pumping and storing beforehand is a good idea.
Hi Sid - thanks for the site, its nice to know im not the only one dealing with this!
I have been suffering with an anal fissure for about 4 months. Sometimes i think its healing but then i might have a bad week and i feel right back were i started - bad week means extreme pain. More recently i feel pain in more than one area - it is possible for another anal fissure to develop?! (i have had no change in diet, i am taking stool softeners as prescibed and going to the toilet each morning). And if yes, what may have caused this?
It's unlikely to have developed a second fissure, I think. As always, the best advice I can give is to be examined. It's important to know for sure what's going on; also, as said in this post, there are several non-surgical methods to achieve healing besides stool softeners. Meanwhile, it's important that bowel movements are both bulky and easy to pass; usually that's best achieved by adding fiber in one form or another: dietary, or fiber supplements.
Hey Sid, I'm a college student, and for the last 2-3 years I've suffered with severe anal fissures. I went to a GI in 2007, and it resulted in a small polyp (non cancerous) being removed from my anus/colon area, a few inches inside my rectum. No LIS, no fissurectomy. Since the fissures are recurring, I wasn't suffering as much at surgery time, and the surgeon only noticed a little scar tissue and a skin tag, but no open wounds. The polyp wasn't my problem, and even though the fissures healed for a while, and recurred every so often, I'm here two years later, in worse pain than ever- suffering sleepless nights, aching days, fearing BM's- its horrible. I really think I need a LIS. As I'm typing this, I'm wide awake at midnight, with my internal sphincter aching horribly. My last bowel movement stung and burned a little, but the pain that has now onset after is almost unbearable, and has been ailing me for about a week now, just like it did two years ago, and even if it naturally heals, it keeps reoccurring, and I believe that surgery is my only option now. I've been suffering too long, used all the suppositories, nitro creams, fiber, etc. I guess aside from being able to discuss this personal topic openly in a great blog like this, my question is, will the LIS stop this horrible aching and spasming that comes after BM's when I have a fissure?? and do you have any advice on how to keep a good mindset while I wait for the surgery?? Im a young college student, and I feel like I'm too young to be suffering from something like this. It's a real downer and restriction on my life sometimes =(
DP: The purpose of LIS is to get a fissure to heal. I wouldn't characterize it as a preventative for future issues. Your story makes me wonder a couple of things: why are you having recurring fissures, and, if the implication of what you describe is that you're having lots of pain while not necessarily having an open fissure, whether the pain is, indeed, related to fissure or sphincter.
As to the first, most recurring fissures are due to recurring problems with constipation, ie, passing hard stools. If that's not the case, I'd wonder if the diagnosis is correct. As to the second, there are other things that can cause anal-area pain, such as prostatitis or levator ani syndrome.
I'd also suggest finding out more specifically about the "polyp." It's not unusual to have a polyp-like thingy at the top of a fissue (called a papilla); but if it was a true adenomatous polyp, ie, a benign tumor-like growth, it's unusual at your age and might indicate a need for further investigation.
Having been a college student once, who found a lump on his belly, I realize I could be freaking you out. Don't mean to. It's not a big deal. But you might want to see an actual colo-rectal surgeon, just to help sort out the possibilities and to confirm the diagnosis.
Thanks so much Sid! I'm making appointments with colo rectal surgeons in Los Angeles as we speak. In terms of my pain, it does only occur when my fissure is open, as it is now. I think the problem I had was that my fissure was healed at the time I saw the GI in '07, so there may have been no basis for a LIS or anything else. One things keeps coming to mind, however: my mom always told me that when I was a baby, I suffered with constipation problems, and strained to make BM's. She said that she though my rectum wasn't large enough and didn't have enough "natural fissures" that expand and contract the anus. She told a doctor and he said as I grew it wouldn't be an issue. I only think of this because she told me my aunt had the same issues, and underwent a form of Lord's operation/anal stretching 40+ years ago. My stools are usually in ok shape, so I wonder if I could have been born with a smaller than average rectum, and that could be causing the fissures to reoccur. And also, would the LIS take some pressure off of my rectum and make stools easier to pass along with healing the fissure?
DP: once the LIS heals, it won't likely leave your sphincter permanently looser, although it's possible. A lord procedure is a good option as well, although it also wouldn't be expected to lead to permanent changes unless there were some sort of scarring that would be broken apart. There are procedures for anal stenosis, which might be an issue to discuss with the surgeon.
I'd be remiss, I suppose, were I to fail to mention another cause of recurring fissure, just for the record.
Haha I understand, every doctor asks about that "factor", and no, never have and never will.
I've been checking out the fissurectomy, and I wonder if my wound is so severe and deep that it would need to be removed surgically. Seems like since it's causing the muscle to spasm and it does bleed, it's beyond healing naturally and staying healed for long.
Hey Sid, good news! I saw a colon/rectal surgeon in Beverly Hills today, and after the examinations and such, I scheduled a date at an outpatient surgery center in for my LIS next Tuesday! After a truly hellish week I was thrilled that I could have the surgery so soon. The examination found I had a pretty decent size fissure, and he also checked if I had too narrow of a rectum, and it appeared that I didn't so I'm happy. There seems to be some light at the end of the tunnel for me now, and even if the fissure takes a while to heal, at least I won't be aching for hours after I make a BM.
Wish me luck, and I'll write back after my operation for sure!
DP: I do wish you luck, and I appreciate that you're keeping me informed. If you're like the patients in my experience, you'll be very satisfied with the outcome.
Thanks for this blog post. I am having surgery on Monday, after trying several options with my doctor. I'm scared, well, sh--less. It's nice to see a good sense of humor about the whole thing. My surgeon does as well. I wish I hadn't waited so long to get help. I honestly would rather give birth again than deal with it any longer. OUCH, hold the walls screaming is right! Mine they think is caused by the diarrhea that comes with my monthly cycle as fiber/veggies/etc and I are friends.
Anyway, I just wanted to pass on my thanks. I've found that more people than you'd think have had this problem. Lucky that most of them were able to heal it with other methods. Me? I've never been so glad to have someone planning to come near me with a sharp object in my life. Bring it on, doc!
I should also say that I'm not actually having LIS, I'm having an "exam under anesthesia" because the doc has been unable to examine, the pain is too great for more than a cursory glance. She is planning an LIS if she finds what I'm pretty sure she will. I don't know how anyone can stand an exam with this going on. Ouchie mia!
Thanks for your comments, and good luck! Not an uncommon approach, to begin with EUA. Docs who try to examine without it, when there's a fissure, are cruel. But there's not much else that causes that sort of pain, so I'd guess you'll wake up a happy woman.
I'm the anonymous from 10/23... interestingly enough, they ended up not doing a LIS. Apparently, it was very ragged and was never going to heal because the skin had actually adhered/grew to the muscle, so she cleaned it up and repaired it. Said the muscle appeared to be okay and not too tight. I certainly hope that takes care of it. I'm in a bit of a pain, but she gave me meds... I hope they start working soon - pain in the ass is right ;)
After treating what I thought was a painful internal hemorrhoid for 3 months I was diagnosed today with a fissure. The pain at times, normally later in the day, many hours after a BM, as described by others is unbearable. I was so convinced that I was dealing with a hemorrhoid that the fissure diagnosis blindsided me and I forgot to ask CR doc a question. The spasming/ pain associated with the fissure migrates toward scrotum and affects urination at times is that common? 44 yr old Male. Starting Nitro cream w/ anesthetic and increase fiber, etc... Thanks for your help.
Not really unusual for the pain to radiate like that.
For the record, internal hemorrhoids aren't painful! If it was your doctor who concluded that, he/she needs to be educated about how and which hemorrhoids cause pain.
This is a response to the "Anonymous" who had the question about the radiation of pain in the scrotum area. While I am not male, I have the radiating pain in my pelvic floor muscles at times, even when I am not urinating and it is extremely painful. For whatever reason, I have discovered that crossing my legs and leaning towards one side of the chair takes it away for me. Hope it helps! :)
Hey Sid, I had my LIS this past Tuesday. I opted for a spinal block and was awake during the operation, so for anyone thinking of that option, its a great alternative to being put under; I didn't feel a thing. I've had one BM since surgery, and it was painful, but that's from the incision wound, which is still pretty sore, and kept me up at night a little. However, my sphincter doesn't go into spasm anymore, so I'm happy to report that the fissure pain and ache is gone, and the only pain now is from the incision wound and the skin tag removal the surgeon also performed, but that pain should go away in a few days.
Thanks for the followup. Sounds like you're on the road to a happy outcome.
I had the LIS surgery about 14 hours ago and so far am experiencing significant post-op pain. You'd mentioned that relief was more or less instant but for me 7.5 mg of lortab just isn't cutting it(as evidenced by my typing this at 3am). Am I dealing with normal pain from surgery that will subside quickly?
Without knowing how the surgery was carried out, it's hard to answer. There is, of course, a range of responses. But this soon after surgery, you should be addressing your questions to your surgeon.
@ Anonymous,
As someone who had the procedure almost a week ago and is still recovering, maybe I can offer you some of my experience so far. The day of surgery and following two days after, the incision wound was sore and swollen, but it's a a different pain altogether. The swelling and ache in my sphincter was instantly relieved, but I'm still in some discomfort making BM's. The skin tag incision still bleeds a little, and still gets a little sore, but the sphincter spasm is gone totally. The best advice I can give is try and make BM's everyday and keep them soft. Believe me, I know that the psychological aspect of it IS tiring. Its hard sometimes knowing that you're gonna be in pain when you sit on the toilet, but it's not as bad as I ever think its gonna be, and theres no long ache after. Just remember when you used to take pain and stress free BM's, and know that with the surgery (if it was performed well) the pain will go away and you'll heal up faster. Its tough man, and its zapped me emotionally/psychologically these past few weeks. Stay strong man, just gotta persevere.
Oh, and also @ Anon,
try and keep the area clean as much as you can. my doctor told me if there was colored discharge or if i developed a fever to get things looked at. but just keep things clean if you can- baby wipes work well. A few more weeks of discomfort, to me, will be well worth it in the future.
I have posted before, but have a few more questions. To refresh your memory, I am a 47 y.o. female who had right hemicolectomy for carcinoid Feb 2009. I had problems with hemorrhoids for years prior to this surgery, and occassional the thrombosed ones, but never a fissure. 1 week post op, I developed what I thought was a thrombosed hemorrhoid, but it turned out to be a fissure. I was examined by a very cold CRS who did a full rectal exam with anoscope while I was crying from pain. Anyway, long story short, I ended up in a general surgeon's office, had a hemorroidectomy with anal dilatation. Fissure remained. Second dilatation. Fissure pain remained until I started miralax AND benefiber. Then I had a BM that was formed (if BM not like toothpaste consistency, it causes problems) and I had a retear. Now I have pain for 3 hours post BM. Not as bad as before, but still not pleasant and my day revolves around "the blessed arrival" as it is now called. Is it likely that I could have SOMETHING done to alleviate my problems? No one has done another anoscope exam as I can not tolerate that, so I do not know if I have scar tissue, or what. The GS says the fissure is healed on the outside but that my sphinctor has retigtened. Please lay out what you think my next steps should be.
Thanks,
Neena
Neena, I really can't lay out a plan because there's no way for me really to know what's going on. It seems sphincterotomy is high on the list of considerations, but that's said with the recognition that I can't know anything for sure and have no basis for a specific recommendation. Other than to say you need more surgical input; maybe the best advice is to find another CRS.
Hi Sid-I wanted to give you an update on my anal fissure and also wanted to hopefully help some other people suffering with a recent breakthrough I discovered! While listening to the radio, oddly enough anal fissures were the topic of the day (was it a sign??) Anyways, the doctor on the show recommended NO creams, ointments or wetting of the area at all (aside from sitz baths and showering), and for those of us who live a busy, normal life to try sitting on a heating pad during the day set on low (instead of 6-7 recommended sitz baths a day-who the heck has time for that)? Quitting my Lidocaine cream cold turkey was scary, but I did it-(hey, I would try just about anything at this point) and nervously drank water, water, and more water while cautiously still continuing high fiber in my diet. I kept it super dry, sat on the heating pad for 5 days and here I am on day 2 of NO BLEEDING and MINIMAL pain!! I will keep up the water and fiber along with this simple plan and keep everyone posted. Could it really have been this simple all along?
That's good; thanks! I did recommend warm baths -- the idea being that the heat relaxes the muscle -- but I don't think a heating pad had occurred to me. Good idea.
Good Afternoon Sid,
Thank you for the great place to express my concerns and issues with respect to anal fissures, as it tends not to be a popular subject to bring up when I hit a sports bar or during lunch with co-workers.
My bout is going on 8 months. My colo-rectal doctor prescribed the cream, sitz baths, more fiber,etc. I have seen him a total of 3 times due to reoccurrences. One was for a hard stool, and the other was because of diarrhea.
I can't but a finger on why the anal fissure began to torture my wrinkly-back-sided-buddy, but in the past I've had a small bout of colitis. It's weird as a 34 year-old, who for the most part considered himself an expert in garbage removal is learning how to correctly take a dump all over again.
Although the the last time I saw my surgeon, he said the fissure has healed better the last few months, diarrhea brings it back (I had gout and took cochisine which caused the dirrhea). It's painful and intimidating when squatting.
To illustrate, if one has ever read about the Guiness record holder who was was able to pull an Airbus from their juevo-sack to the tune of 50 yards, one knows the guy who pulls big airplanes with his junk needs to have a special mindset. I guess I equate that mindset when I step in the John accompanied by a fissure.
I find myself looking at strangers or acquaintances differently now. I selfishly say to myself when I see people enjoying themselves, I bet those pr!cks never had to deal with a fissure, or will tease someone who has one!
At the risk of sounding repetitive, I've pinpointed my recurrences on diarrhea. Miralax and fiber keeps my BM's soft. I'm in Mexico very frequently, and as the Mexican bumper sticker says; "Diarrhea Happens".
Is it true that the more the fissures spasm, the more likely the result to become chronic?
I do sit a lot and it's difficult to concentrate and get work done when my back door feels like it's being remodeled by inexperienced journeymen who should have been reported to Angie's List.
I've narrowed my options down to botox (which is temp.) and the LIS, which is known as the gold standard of fissure surgeries.
I don't care about the cost, however, I do care about recovery time, and incontinence. Quite frankly, that baseball sized seepage story creeped me out a little.
What questions should I ask to make sure my Colo-rectal guy is the best man for the job?
Thank you in advance.
Regards,
Manny Bernal
Well, I suppose you should express your concerns about leakage and ask what his experience is with it, and if it's ever occurred in his patients, what he's done about it.
Thank you Dr. Schwab for your response.
I have an appt. next week and I will bring that question up. I think it's always good to get several opinions. Have you seen or read anything about the LIS procedure causing incontinence years down the road?
Regards,
Manny B.
Manny, I haven't read or heard of delayed problems; which is not to say it doesn't exist. Still, anatomy and physiology would suggest, I'd think, that if it doesn't happen at the time, it wouldn't later, absent some other pathology.
Dr. Schwab,
Again, I thank you for your response. I had my appt.,all 10 minutes of it (my questions written down)...I was probed and my fissure is now officially chronic. I'm not sure if my doctor understood my trip out of the country isn't occurring for another 5 weeks and not tomorrow. He said he doesn't want to do anything until I get back due to risk of infection (LIS procedure), at that point, he'd look over both LIS and botox options (which he stated patients opt for in place of surgery).
I took your advice and asked about "seepage" and incontinence(this is why this blog is very helpful), and was told colo-rectal surgeons don't initially like to do the LIS procedure because of possibility of incontinence "not right away, maybe down the road".
As for pain issues,I was prescribed more sitz baths.
Also, I was given a prescription that curtails diarrhea other medications might invoke, i.e. colchisine. Again, I'm not sure if I communicated effectively that a medication caused this flare up, but not other flare ups I've experienced. Flare ups are caused entirely from food. I take Miralax and fiber supplements to combat the opposite effects (constipation).
I'm following up with the same doctor to make sure my questions were understood & I think it might be wise to get another opinion as well.
I enjoy checking the blog, I appreciate your advice regarding this painful issue.
Thanks Dr. Schwab.
Regards,
Manny
Sid-I think I have done it! I have achieved "poo perfection" and am well on my way to a full recovery! I felt the need to share this with everyone who was in the same boat, hoping that my personal blend of "methods of success" might end the suffering for those stuck in the vicious evil cycle and feel they are out of options.
1)Run (don't walk) to get a heating pad if you don't already have one. This has been a life saver for me. I sit on it during the day on low and it has relieved the horrific ache in lieu of the sitz baths I was unable to do during the day.
2)Dryness is your FRIEND. Sitz baths at night, but no creams, ointments, jellies.
3)Drink at least 2 liters of water daily to keep things moving. I bought a 1 liter bottle and fill it up 2 times a day.(Trust me, this makes a big difference in keeping stools soft).
4)Continue fiber-friendly foods.
5)If you can't live without coffee (like me) I began making a 75% decaf with 25% regular mix and this also made a big difference. Not only does it not irritate your stomach, it assists in the process of keeping things moving at a healthy pace.
6)I quit the stool softeners once I reached the point of a comfortable consistency. Otherwise, they were messing up my schedule.
Each day has been better and better, and I just cancelled my follow-up with the colo-rectal surgeon because I don't need it. I have been healing nicely and am currently at a point of no pain and no bleeding during bowel movements for 18 days. I am still following my plan religiously to prevent relapse, and I hope this helps a few folks out there.
I am scheduled to have a LIS and skin tag removal next Monday. I am thirty-two years old with four children under the age of five. I am not worried about the pain or healing time, but completely scared about the risk of leakage! I know there are risk to every surgery, such as the risk of death under anesthesia, but I am frankly more worried about leakage. Are there cases when a surgeon cuts more or less of the muscle? If a patient were to tell you how scared they were of this risk, would you be more conservative with the cut? Do all doctors cut the small sphincter muscle? Would the complication of leakage be less with a Fissurectomy? Would it make any since to have the skin tag removed and try to correct the fissure through diet? My doctor has done this for 15 years and has never had a leakage problem, but I do not want to be the first! What would I need to say to you, if you were preforming my surgery, to convey how conservative I would like the cut to be? One last question. I have been advised to have my gallbladder removed, but have decided to hold off until I am really hurting. I have been told, one may have loose stools after gallbladder removal. Would this make me at a higher risk for leakage if I ultimately did have to have my gallbladder removed? Meaning, with the two surgeries combine (LIS and gallbladder removal) am I in a high risk group for leakage?
Thanks so much for your help!
Kauleen
Kauleen: LIS is what it is; ie, one cuts the internal sphincter, no more or less. So doing it "conservatively" doesn't really apply. The question is whether, given your concerns, all other options have been tried, and failed: ie, botox, nifedipine, etc. There's also the Lord procedure, which is just stretching of the muscle. Fissurectomy, without any attention to the muscle, really isn't likely to do anything.
As to the skin tag, I can't really know what it is to which you refer: if it's the sort of papilla associated with fissure, I don't think removal, alone, will accomplish anything with respect to healing the fissure. If it's affecting hygiene, that's another matter.
Like your surgeon, I haven 't had patients troubled with leakage after LIS. I suppose if a person had it, and then had gallbladder surgery and was among that small number who had problems with diarrhea, the problem could be magnified. It'd be like being struck by lightning twice.
I really think it is great that you respond so quickly to our questions. I just wanted to first thank you. My last two questions: Is there a risk of leakage with a fissurectomy as there is with a LIS?
Secondly, what is the best source to use to check out a Doctor's credentials?
Once again, Thank you very much,
Kauleen
Sorry, I lied! One last thing ( for now)! Why don't you suggest excising the fissure?
Thanks,
Kauleen
There is less risk of leakage with fissurectomy. I didn't generally do fissurectomy with LIS because if the LIS is adequate the fissure should heal, and I didn't like to add the extra digging around in the area. However, I'm a general surgeon who trained when there were few if any colorectal specialists (I don't think the specialty existed when I trained.) So don't take my word.
As to checking credentials, given your concerns I'd suggest seeing a colorectal specialist and being sure he/she has had a full fellowship and is board certified.
What a great site! I'm so glad that I found it. I've had 2 fissures. The first one healed on its own but the second one was much more painful and deep. My surgeon said that I needed the LIS procedure. It was a easy procedure and it did help alleviate a great majority of the pain. My questions are:
1. How long does it take for fissures to heal after the LIS? It's been 2 weeks and I'm still having a lot of pain with BM's and some bleeding (even with copious amounts of fiber).
2. I have a hard "lump" where the fissure starts. Is this normal? Will it also go away when the fissure heals? My surgeon said she was not concerned about it and did not want to remove it but it seems to be where the majority of the pain is coming from.
Thanks so much!
Healing time varies, although the pain relief is usually much sooner. I can't really offer much regarding the lump, being unable to see it. This early in the post-op period, you'll get much better info from your surgeon. You should keep her informed about what's going on and how the lump is behaving.
Thanks for your great blog. I’ve scoured the net for information on fissures and this is a goldmine. Here’s my story: I was diagnosed with an anal fissure two years ago. It comes and goes. It took me about two months to get over it the first time around. Since then fissures have reappeared maybe 20 times and lasted for anywhere from a few days to a few weeks.
The pain is mostly stinging during and after defecation, sometimes with a streak of blood. The pain usually lasts 5 or 10 minutes but I’ve had bouts of pain that lasted for much longer (as long as three weeks). I’ve had episodes of spasm-like deep anal pain, but not often. Usually it’s just the stinging, burning, bleeding feeling that goes away after a hot bath.
Between bowel movements the pain usually goes away completely, but I have to be very conscious of my diet and my intake of fluid, fiber and stool softeners all the time, and even with all the attention I pay to it , I still get fissures all the time. It seems like they’re getting more frequent as time goes on. They are painful and very annoying but not incapacitating.
I have seen two specialists. The first one prescribed diltiazem cream but it gave me a rash (and a nasty anal abscess—ouch!) and I had to stop. I got a second opinion from a surgeon who suggested LIS. I went back to the first specialist, and she said that people shouldn't consider that surgery unless they're really desperate, because it's risky. Since I don't usually have the spasms and I’m not in constant pain, she thinks I shouldn’t have any surgery.
During a recent bout of fissure pain, I made an appointment to see the surgeon again, but by the time the appointment came, the fissure healed itself. She said there was nothing there to operate on. Sure enough, two weeks later I had another nasty fissure episode with pain that lasted for several weeks. So, was it really healed? I wonder, what does it mean that the fissure keeps coming back, even though it may disappear completely from time to time? Should I be considering surgery at this point? I’d soooo like to put this ‘behind’ me once and for all...
Anyway thanks in advance for any insight you might be able to offer...
Paul V.
In my experience the main cause of recurring fissures is repeated episodes of constipation. If you are not, in fact, having hard and difficult-to-pass stools, then other things might need to be ruled out, although it's rare that there'd be no other manifestations: inflammatory bowel disease, in particular.
From far away, I don't want to get into making specific recommendations about surgery (LIS or Lord procedure) vs other options. From what I've written here already, in the post and in comments, I think I've covered the generic info I have to offer.
Hello -- thank you so much for having such an informative page and answering people's questions. About ten days ago I started to have terrible pain in the ass, especially immediately after a bowel movement, when it would clamp or spasm. It was accompanied by a small lump, slightly smaller than a fingernail, next to my anus. My doctor said it was an anal fissure, said she noticed some pus, and prescribed a course of antibiotics. I wonder if I could ask a couple questions of my own?
i) is it normal for it to be painful while walking, getting up and sitting down, and (especially) when coughing and when going up or down stairs?
ii) in the last couple of days it has thankfully started to get much less painful. After a bowel movement I now have either a painless spasm or no spasm at all. And I am able to get up and walk around without pain, so I think it is recovering. But there seems to be a transparent discharge, sometimes tinted very faintly pink, from the area. Is this a problem or sign it is still infected? Should I go back to the doctor?
iii) I'm very keen on exercise and miss the gym. Is it ok to begin weightlifting again, or will that put too much strain on the area?
Thanks very much for all your help!
Everything you describe is consistent with fissure; however, I can't make any sort of definitive diagnosis from over here. Having some discharge from any open wound is common; in fact, I don't think I ever prescribed antibiotics for a simple fissure.
I'd not think weightlifting would have an effect one way or the other, assuming it's a fissure; but if you find it causes the area to hurt, you should stop. And, of course, any persisting symptoms which aren't improving means another visit to your doctor.
I'm the person that just asked about weightlifting, above. I was able, with a digital camera, to get a close look at the bump next to my anus, and I noticed it has a white head -- rather like an acne pustule. I've booked another appointment with my doctor, but won't see her till thursday. Is this a sign that it's infected? Am I in trouble?
First of all, congratulations on your clever method of observation. Somewhere on this blog I wrote about the role of digital photography in similar situations, with patients emailing pics of healing wounds to their docs when there were questions of infection. You might consider doing the same.
I hesitate to offer an opinion without being more directly involved. I'd say you should either describe or send the photo to your doc and leave the decision up to her as to whether you should be seen sooner.
I must remember to delete them before I show everyone my holiday snaps.
I have always been constipated, and irregular (53 years). On Aug 21, 2009, I had an especially difficult bm. I had sever pain and itchy, which I naturally scratched the hell out of. I have been in pain ever since.
I went to my PCP in late October. He told me many of the things you have mentioned in your excellent blog. I have been on MiraLax and BeneFiber since then. I have become regular and less intense. But the pain is still here. Sometimes it seems as if it is going to go away and then back it comes.
Right now it hurts. I have several "spots" but since I can't see them, I am not sure if they are located where you are describing. I believe I have one or two that are on the sides rather then being in the mid line. I can feel the "skin tags".
What should my next step be?
See your doctor again.
Sid,
As others have said, it's great to find your site, and am amazed by the speed of your replies! I have a renewed faith in humanity!
Like so many others here, I have a fissure that has been flaring up lately after a particularly problematic, constipated BM. In the past, when the fissue was aggravated, the pain after a BM would last for only 10 minutes or so. This time, it seems to be more like 4 of the longest hours of my life.
Of course, I've boosted the fiber in my diet (Metamucil), but I suspect this is aggravating the problem. Yes, it makes the BM softer, but it also seems to increase volume in such a way that it is harder to pass. I understand that this is good for gentle stretching under normal circumstances, but right now it just seems to be reopening the wound. I'm in search of a way to break the cycle of BM->tear->pain->BM->tear etc. So, is there an alternate type of fiber you would recommend or other approach that would let it heal far enough to take the stress of a normal BM?
Many Thanks!
-RC
During the healing process, I recommended to my patients that, in addition to the fiber, they add a tablespoon or two of mineral oil twice a day. This presupposes the diagnosis is correct, which I have no way of knowing in your case. I just wrote an addendum to my original post, and I hope you'll read it.
Sid,
Had LIS 12/15, it is 12/19 and still hurts (incisionally, like a bruise and burning with BM). Also feels a bit jagged in there with some leaking of scant blood. I had two big fissures so I'm sure the surgery was extensive. I want to be pain free but at least don't have post bm pain- it's been a year with these fissures! Any time averages known re: relief from incisional pain and that during a BM? day 1 was horrible, day 4 is better but not great; I'm looking for perfection! I'm a Nurse Practioner student and this almost took me out of the program! Thanks for your feedback. Jamie
As I said in the recently-added addendum to the original post, I don't want to get into specifics because I can't know what's going on. "Average" recovery depends on the specifics of the operation, and I don't want to hazard a guess as to the normality of an unknown. Early post op questions are best directed to the surgeon who did it.
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