Post-Anal Fissure Discomfort: When to Seek Further Evaluation

The anal fissure has healed, but it feels strange?

Hello, Dr.
Ko! I had a follow-up appointment on May 2nd, where the doctor used an anoscope to examine me closely and said that my anal fissure had healed.
However, I still feel discomfort in the deeper mucosal tissue; sometimes there is slight pain that radiates to the surrounding area.
The doctor performed a digital examination and felt a soft area without any bleeding, so he advised me to continue sitz baths and take medication, but to avoid using the ointment for now, as it might be causing irritation.

Today (May 5th), I returned for another check-up because after using the restroom yesterday, I noticed that my stool has been somewhat dark for over a week, appearing almost black, but when rinsed with water, it was a deep brown color.
The doctor reassured me that there were no wounds (everything looked fine).
He mentioned that the anoscope only allows visualization of the anal canal, and for a deeper examination, a sigmoidoscopy would be necessary, which requires bowel preparation.
Last March, I had a colonoscopy that revealed three very small polyps, which were biopsied and identified as adenomas.
Because they were small, both the gastroenterologist and colorectal surgeon suggested waiting two years for the next procedure.
However, other hospitals or clinics have recommended that I undergo another colonoscopy this year.

In early April, I had a hemorrhoid banding procedure on the right side (I had previously undergone banding on the left side and posterior).
Later, in mid-April, I experienced diarrhea for three days, which led to a right-sided anal fissure.
I continued with sitz baths and medication, and the fissure has healed.
I also consulted a gastroenterologist for my irritable bowel issues, and the medication has helped maintain soft stools.

Now, I still feel discomfort on the right side internally.
The doctor mentioned that many patients experience unexplained pain despite normal examinations, which could be due to heightened nerve sensitivity or anxiety, and that surgery may not provide a solution.
I was somewhat reassured, but then this evening while using the restroom, I noticed a small amount of bright red blood, despite not having eaten any tomatoes or foods with red dye.
After my sitz bath, I applied ointment internally, but I'm unsure if this is due to a ruptured internal hemorrhoid or an issue with the mucosal lining.
I have another appointment next Thursday to discuss whether to proceed with another colonoscopy (since a sigmoidoscopy also requires bowel prep, it might be more efficient to do a colonoscopy again).
I was initially using the ointment prescribed by the hospital, but I have now switched to a product called Yizhi Kang, as it is the only one without steroids.
I am concerned that the previous steroid ointment may have caused irritation.
Can hemorrhoid ointments damage the internal mucosa?
Additionally, I have been feeling mentally unwell and easily fatigued over the past month and a half.
I wonder if this could be a side effect of the pain medication prescribed, which is Dolan.
My family has also noticed that I have lost a significant amount of weight, and I feel that my pants are getting looser (I suspect this may be related to my irritable bowel syndrome, as my gastrointestinal issues have persisted since New Year's Day, leading to frequent diarrhea).

So, do you think I need another colonoscopy? The gastroenterologist mentioned that last year's colonoscopy did not indicate Crohn's disease, so I recently had blood tests done, and I will review the results in two weeks.
When I heard the doctor mention "air in the intestines" while reviewing last year's data, I was unsure what that meant (or if I misheard).
During last year's colonoscopy, I experienced significant bowel movements during the preparation phase, approximately ten times, which made my anus feel very uncomfortable.
The doctor noted that my intestines are more sensitive than most.

I am worried that if I undergo another procedure, the bowel prep could lead to another anal fissure, as it is still healing and may be vulnerable.
After all, anal fissures take a considerable amount of time to heal.
Lastly, now that my anal fissure has healed, could there be scar tissue causing ongoing discomfort, or is there a possibility of a hidden fistula? The digital examination and anoscopy were thorough, and I also had an upper endoscopy in February, which was normal.

The discomfort on the right side persists; I do not feel anything when I contract my anal sphincter, but I do feel sensations when I relax.
I have been trying to perform anal contractions when I can, but I am uncertain about the underlying issue, as I have never experienced anything like this before.
Thank you, doctor!

Hǎo qí guài, 20~29 year old female. Ask Date: 2016/05/05

Dr. Ke Fangxu reply Surgery

If the pain and bleeding caused by anal fissures are not severe, it is generally not recommended to continuously use medications or undergo procedures such as ligation.
Maintaining good lifestyle and bowel habits is sufficient.
For mild discomfort, warm sitz baths can be helpful.
If a colonoscopy has been performed and no significant issues were found, there is no need to repeat it in a short time.
It is advised to relax and not to worry excessively.
Only seek medical attention if the pain becomes severe or if there is significant bleeding; otherwise, frequent examinations and invasive treatments may cause further damage to the anal area.

Reply Date: 2016/05/05

More Info

Understanding post-anal fissure discomfort can be quite complex, especially when symptoms persist despite treatment. It seems that you have been experiencing ongoing discomfort in the anal region after your fissure healed, and this can understandably cause concern. Let's break down your situation and address your questions systematically.

Firstly, it’s important to recognize that after an anal fissure heals, some patients may still experience discomfort due to several reasons. This discomfort can be attributed to residual sensitivity in the anal area, scar tissue formation, or even muscle tension in the anal sphincter. The fact that your doctor noted the fissure has healed is a positive sign, but it does not rule out the possibility of other issues, such as internal hemorrhoids or muscle spasms.

Regarding the dark-colored stools you mentioned, it’s crucial to monitor any changes in your bowel habits and stool appearance. Dark stools can sometimes indicate bleeding higher up in the gastrointestinal tract, but if the color changes upon rinsing, it may not be a cause for alarm. However, the presence of fresh blood in the toilet after a bowel movement is concerning and should be evaluated further. It could indicate a variety of issues, including hemorrhoids, fissures, or other gastrointestinal conditions.

Your doctor’s recommendation for a colonoscopy is prudent, especially given your history of adenomatous polyps. While the previous polyps were small and benign, it is essential to keep monitoring your colon health, particularly if you are experiencing new symptoms. The fact that you had a colonoscopy last year and were advised to wait two years for the next one does not negate the need for further evaluation if new symptoms arise.

As for the medications you are using, switching to a non-steroidal hemorrhoid cream like Yizhi Kang may be beneficial if you suspect that the steroid cream was causing irritation. Steroid creams can sometimes thin the skin and lead to increased sensitivity, so it’s reasonable to try a different approach. However, always consult your physician before making changes to your medication regimen.

The mention of "气腸" (which translates to "gas intestine") likely refers to increased gas or bloating in the intestines, which can be a symptom of irritable bowel syndrome (IBS) or other gastrointestinal disturbances. Given your history of bowel issues, it’s essential to discuss these symptoms with your gastroenterologist, especially if they are affecting your quality of life.

In terms of your weight loss and fatigue, these could be related to your gastrointestinal symptoms, especially if you are experiencing frequent diarrhea or changes in appetite. It’s important to address these concerns with your healthcare provider, as they may need to investigate further to rule out any underlying conditions.

Finally, regarding the possibility of a hidden fistula or scar tissue causing discomfort, this is something that can be evaluated through further imaging or examination. If your symptoms persist or worsen, it may be necessary to consider additional diagnostic procedures, such as an MRI or a repeat colonoscopy, to ensure there are no complications.

In summary, while your fissure has healed, ongoing discomfort can arise from various factors. It is essential to maintain open communication with your healthcare team, report any new or worsening symptoms, and follow their recommendations for further evaluation. Your health and comfort are paramount, and addressing these concerns proactively will help ensure the best possible outcome.

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