Managing Recurrent Anal Fissures in Children: Treatment Options and Concerns

Recurrent anal fissures in children for two years?

My son is 8 years old and has been suffering from anal fissures for the past two years.
After seeing a doctor, he started taking magnesium oxide and lactulose syrup.
After nearly two years of treatment, the effectiveness of the medication has decreased.
Previously, when he was on medication, he rarely experienced anal fissures, but now he still has them every week despite taking the medication.
He continues to take stool softeners daily.
Over the past two years, we have consulted four surgeons (at Mackay Memorial Hospital and Chang Gung Memorial Hospital) and two gastroenterologists, who only suggested dietary improvements and medication, without recommending surgery.
My son currently drinks 1800cc of water daily, eats vegetables with every meal, consumes three types of fruit each day, and only has a small amount of meat in one meal.
His weight has not increased for almost six months.
He has a bowel movement every morning after breakfast and takes a warm sitz bath afterward.
Sometimes his stool is hard at the beginning, and other times it is completely loose.
I would like to ask the doctor the following questions:
1.
The surgeon prescribed glycerin suppositories, and after one month of follow-up, we have been purchasing them from the pharmacy ourselves.
Over the past two years, we have used nearly 200 suppositories (averaging 10 per month).
What are the potential side effects of long-term use? Why do suppositories help with anal fissures while ointments do not?
2.
Can surgery improve the issue of recurrent anal fissures? Is it appropriate to perform surgery at this age considering the immature development of the anal sphincter?
3.
Are there other methods to improve recurrent anal fissures? Thank you, doctor.

Mr. Yang, 40~49 year old female. Ask Date: 2017/11/22

Dr. Ke Fangxu reply Surgery

1.
Rectal suppositories should not be used long-term; if there is no improvement after prolonged use, a consultation with a physician is recommended.

2.
If conservative treatment for anal fissures is ineffective, surgical intervention may be the only option.
At the age of 40, there should not be any undeveloped issues, but whether surgery is appropriate should be evaluated by a physician.

3.
The typical symptoms of anal fissures include pain during bowel movements accompanied by slight bleeding, often caused by constipation or diarrhea.
The fundamental treatment is to address the bowel movement issues, and warm sitz baths can be beneficial.
Over-the-counter hemorrhoid suppositories can also be used.
If symptoms persist without improvement, it is best to consult a physician.

Reply Date: 2017/11/22

More Info

Managing recurrent anal fissures in children can be quite challenging, especially when conservative treatments seem to lose their effectiveness over time. Your son’s situation, where he has been dealing with anal fissures for two years despite dietary adjustments and medication, is not uncommon. Here’s a comprehensive overview of the treatment options and considerations for recurrent anal fissures in children.

1. Long-term Use of Suppositories
The use of suppositories, such as those containing glycerin or other laxatives, can help soften stools and promote easier bowel movements. However, long-term use of any laxative, including suppositories, can lead to dependency, where the bowel becomes reliant on the medication to function normally. This can result in decreased bowel motility and potentially worsen constipation when the medication is stopped.
The reason why suppositories may be more effective than topical ointments in some cases is that they can provide more direct lubrication and stool softening in the rectal area, which can help reduce the pain associated with passing hard stools. However, it’s essential to monitor your son’s bowel habits and consult with a healthcare provider about the long-term use of these medications to avoid potential side effects.

2. Surgical Options
Surgery can be considered for children with recurrent anal fissures, especially if conservative treatments fail. The most common surgical procedure for chronic anal fissures is lateral internal sphincterotomy, which involves cutting a portion of the anal sphincter muscle to relieve tension and promote healing.
In children, the anal sphincter is still developing, and there are concerns about the appropriateness of surgery at a young age. However, if the fissures are significantly impacting your son’s quality of life and conservative measures have been exhausted, surgery may be warranted. A pediatric surgeon with experience in this area can provide guidance on the risks and benefits specific to your son’s case.

3. Additional Treatment Options
In addition to dietary changes and medications, there are several other strategies that may help manage recurrent anal fissures:
- Dietary Fiber: While your son is already consuming fruits and vegetables, it may be beneficial to ensure he is getting enough soluble fiber, which can help soften stools. Foods like oats, beans, and psyllium husk can be effective.

- Hydration: Continuing to encourage adequate fluid intake is crucial. Water is essential for preventing constipation and ensuring soft stools.

- Regular Bowel Habits: Establishing a routine for bowel movements can help. Encourage your son to sit on the toilet for a few minutes after meals to promote regularity.

- Warm Sitz Baths: Continuing with warm sitz baths after bowel movements can help soothe the anal area and promote healing.

- Topical Treatments: While you mentioned that topical ointments have not been effective, some children may benefit from prescription topical treatments that contain nitroglycerin or calcium channel blockers, which can help relax the anal sphincter and promote healing.

Conclusion
Managing recurrent anal fissures in children requires a multifaceted approach. While dietary modifications and medications are essential, it’s crucial to monitor your son’s progress and consult with healthcare professionals about the potential need for surgical intervention. If you have concerns about the long-term use of suppositories or the effectiveness of current treatments, seeking a second opinion from a pediatric gastroenterologist or a colorectal surgeon specializing in pediatric care may provide additional insights and options.
Ultimately, the goal is to improve your son’s quality of life and resolve the discomfort associated with anal fissures while minimizing any potential side effects from long-term medication use.

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