Managing Chronic Anal Fissures: Effective Treatments Beyond Surgery

Blood at the end of the stool due to anal fissure?

Hello Dr.
Ke,
About two months ago, I experienced rectal bleeding during a bowel movement (there was blood on the stool and also on the toilet paper).
After that, for about a week, the surface of the stool was stained with blood, and I felt pain when passing stool.
When I inserted my finger to apply medication, it was even more painful.
Sometimes, I also experienced anal pain for several hours after a bowel movement.
I consulted a colorectal surgeon who diagnosed me with anal fissures and mentioned that my anal canal is relatively narrow, suggesting that if the condition worsens, surgery might be considered.

Since then, I have been applying ointment and taking warm sitz baths twice a day (using non-alcoholic iodine).
Over the past month, I have seen improvement; the pain during bowel movements has decreased significantly, and the post-defecation pain is mostly gone.
However, I still experience bleeding once or twice a week (the blood is minimal and only on the surface of the stool).
My bowel movements are generally normal; I drink about 300cc of water in the morning, and within 5-10 minutes, I feel the urge to go.
The stool passes quickly and is mostly well-formed and of substantial volume.
After lunch, I usually take a short nap and then have another bowel movement, which tends to be softer (and I have not experienced bleeding with softer stools).

However, if my morning bowel movement is larger, or if the stool is coarse or hard, there is sometimes a small amount of blood on the surface of the stool.
I would like to ask Dr.
Ke if I should continue with the warm sitz baths (with non-alcoholic iodine) and ointment, or if there are more effective methods to improve this condition, as it seems to have become a chronic anal fissure.
Is there a better approach besides surgery, or is it just a matter of long-term management? Additionally, does rectal bleeding from anal fissures typically occur at the finer end of the stool or at the end where it may break off? I feel that if the stool is coarse and hard at the front, it may cause a tear and bleed, and the blood ends up on the tail end of the stool.
I am concerned about other potential conditions since the blood is always at the end of the stool.
I am now drinking a large amount of water (3000cc daily) and eating more vegetables.

Thank you for your guidance.

A-Dai, 30~39 year old female. Ask Date: 2018/05/30

Dr. Ke Fangxu reply Surgery

Chronic anal fissure is a troublesome condition that, while not severe, often does not respond well to conservative treatment.
The only relatively effective option is surgery.
If you prefer to avoid surgery, your current approach is sufficient, and you can additionally use topical ointments and suppositories.
If you are concerned about other underlying conditions, a colonoscopy is necessary.

Reply Date: 2018/05/30

More Info

Managing chronic anal fissures can be a challenging and often painful experience. Your symptoms, including bleeding during bowel movements and pain, suggest that you may be dealing with a chronic anal fissure, especially since you have already seen a colorectal surgeon who confirmed the diagnosis. Chronic anal fissures can occur when there is a tear in the anal lining, often due to passing hard or large stools, which can lead to significant discomfort and bleeding.

Non-Surgical Treatment Options
1. Dietary Modifications: It sounds like you are already making some positive changes by increasing your water intake and consuming more vegetables. This is crucial, as a high-fiber diet can help soften stools and reduce straining during bowel movements. Aim for a fiber intake of at least 25-30 grams per day, which can be achieved through fruits, vegetables, whole grains, and legumes.

2. Topical Treatments: You mentioned using a topical ointment. Medications such as nitroglycerin ointment or calcium channel blockers (like diltiazem) can help relax the anal sphincter and promote healing. These medications can be applied directly to the fissure and may reduce pain and promote blood flow to the area, aiding in healing.

3. Warm Sitz Baths: Continuing with warm sitz baths is beneficial. Soaking the anal area in warm water for 10-15 minutes several times a day can help relieve pain and promote healing by increasing blood flow to the area. Adding non-alcoholic iodine to the bath can help with hygiene, but ensure that it does not irritate the skin.

4. Hydration and Stool Softeners: Staying well-hydrated is essential, as you are already doing by drinking around 3000cc of water daily. Additionally, consider using stool softeners or fiber supplements (like psyllium husk) if you find that your stools are still hard or difficult to pass. This can help prevent further irritation to the fissure.

5. Pain Management: Over-the-counter pain relief medications, such as ibuprofen or acetaminophen, can help manage pain during bowel movements. However, consult with your healthcare provider before starting any new medication.

When to Consider Surgery
If your symptoms persist despite these conservative measures, surgical options may be considered. Surgery for chronic anal fissures typically involves a procedure called lateral internal sphincterotomy, which involves cutting a small portion of the anal sphincter muscle to relieve tension and promote healing. This is usually considered when non-surgical treatments have failed after a reasonable period, typically several months.

Monitoring Symptoms
Regarding your concern about the bleeding being localized to the tail end of your stool, this is common in cases of anal fissures. The fissure often occurs at the posterior midline of the anal canal, and when hard stools pass, they can exacerbate the tear, leading to bleeding. It is essential to monitor your symptoms closely. If you notice any changes, such as increased bleeding, changes in stool consistency, or new symptoms, you should consult your healthcare provider promptly.

Conclusion
In summary, managing chronic anal fissures effectively often requires a combination of dietary changes, topical treatments, warm sitz baths, and proper hydration. While surgery is an option if conservative measures fail, many patients find relief through non-surgical methods. Continue to monitor your symptoms, and if you have any concerns or if your condition worsens, do not hesitate to reach out to your healthcare provider for further evaluation and management.

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