Post-Surgery Concerns: Delayed Healing and Medication Queries for Hemorrhoids

I would like to inquire about the delayed healing of the wound after mole removal surgery and medication issues?

Hello Dr.
Ke, on March 18 of this year, I underwent surgery for internal hemorrhoids at Hospital A.
However, since last September, I have already had three anal surgeries at Hospital B, including procedures for anal fistula and hemorrhoids, as well as a surgical repair for an infected anal wound that bled significantly.
The reason I went to Hospital A for surgery in March was that a doctor at Hospital B discovered that many years ago, during a hemorrhoidectomy, there were still internal staples left in my body that had not been removed, which were protruding and potentially injuring the skin inside my anus, raising concerns about infection.
I had no choice but to return to my original hospital (Hospital A) to have the staples removed (since the doctors at Hospital B would not do it) and to address the issue of painful and bleeding anal fissures that occurred during bowel movements.
However, it turned out that there was only one staple, and removing it was sufficient.
The doctor also removed a small internal hemorrhoid, which had been bleeding frequently during bowel movements, leading other doctors at Hospital B to suspect it was a result of scar tissue from previous surgeries.
Interestingly, the doctor at Hospital A, who had previously performed the hemorrhoidectomy, stated that I did not have an anal fissure at all; he only removed a small internal hemorrhoid and three small polyps (which were benign according to the biopsy results).

However, it is quite concerning that throughout the nearly three months of my visits to Hospital A, the doctor never performed a digital rectal examination or anoscopy to determine whether the bleeding during bowel movements was due to an anal fissure or hemorrhoids.
(The reason given was the concern that external pressure might harm the surgical site; the first real examination of my anus was only conducted after I was under general anesthesia.) The doctor also seemed unwilling to answer some of my related questions, which has left me worried, prompting me to seek your advice, Dr.
Ke!
1.
In a state of general anesthesia where the muscles are fully relaxed, can the anus expand significantly? If there is an anal fissure at that time, could the expansion cause the fissure to fully open, making it visually undetectable?
2.
It has been nearly two months, and I still notice blood during bowel movements (though there is not much pain, only a couple of instances of sharp pain like a cut).
The doctor insists on not performing any invasive examinations like a digital rectal exam and has advised me to take stool softeners and start using suppositories, suggesting I return in another month.
However, I am worried that there may be other issues that he is not addressing promptly, which could lead to more complications.
Can I seek another specialist, such as a trusted doctor at Hospital B, for an examination? Is it appropriate to perform a digital rectal exam and anoscopy two months post-surgery? (I had a colonoscopy earlier this year, which was normal, so intestinal issues can be ruled out.)
3.
During my follow-up on May 14, the doctor prescribed a month’s supply of Faktu suppositories (policresulen, Cinchoca) and Yizhi Kang ointment, instructing me to use one suppository morning and night and to apply the ointment before inserting the suppository.
Is it acceptable to use the suppositories twice daily for a month? (I have read reports online that if symptoms do not improve after one or two weeks of using suppositories, one should stop and discuss the next steps with a doctor to avoid potential harm to the anal mucosa, and I have already undergone several courses of suppository treatment in the past few months.) Alternatively, how long would you recommend using them to allow the anus to rest before consulting another physician for further discussion and examination?
4.
I currently take warm sitz baths after bowel movements, ensuring the water is not too hot (as many hospitals recommend sitz baths at around 42 degrees Celsius for optimal relaxation of the anal muscles, which is also a suitable temperature for bathing infants; although this temperature is not scalding, it is warmer than just warm water).
Is this temperature appropriate, or should it be lukewarm? The 42-degree temperature is indeed very comfortable and quickly alleviates discomfort in the anal area, but the doctor mentioned that excessive heat could impair wound healing and potentially lead to hemorrhoid formation.
Is this true? What temperature should I use, and how long should I sit in the bath given my current condition?
5.
Is it currently suitable for me to perform kneeling prostrations and sit cross-legged for meditation?
6.
I experience diarrhea from the stool softeners, but since I am vegetarian, I do not suffer from constipation and have regular bowel movements twice a day.
The stools are formed but slightly firmer than those produced by the stool softeners; however, they are not difficult to pass, and there is no pain in the anus.
Will not taking stool softeners and having bowel movements like this hinder the healing of my wound? Generally, how long should I wait before discussing and examining with a doctor if the wound is not healing well?
7.
If there is indeed a scar tissue anal fissure that continues to bleed during bowel movements and does not heal, is it possible to perform a surgical procedure to relax the internal anal sphincter and repair the fissure? What are the chances of success with this surgery? If the anal canal is not narrowed, could this surgery result in excessive relaxation of the internal anal sphincter, leading to complications such as incontinence?
I have many questions, but I am truly grateful for your response, Dr.
Ke!

A Guo, 40~49 year old female. Ask Date: 2019/05/14

Dr. Ke Fangxu reply Surgery

1.
Anal fissures cannot occur as a result of stretching the anal opening, as there would be no injury present.

2.
If the colonoscopy shows no abnormalities, performing a digital rectal examination or anoscopy will not yield new findings, but it can help assess the extent of wound healing.

3.
If the bleeding is not severe, it is acceptable to avoid using suppositories.

4.
The water temperature for sitz baths is generally recommended to be no higher than 40 degrees Celsius; the purpose of warm sitz baths is to promote relaxation through the heat reflex of the anal area.
Water that is too hot can cause anal contraction, which may irritate the wound.

5.
It should not have any impact.

6.
If taking softeners leads to diarrhea, you should discontinue the medication.
If stopping the medication results in difficulty with bowel movements, fiber supplements can be used to improve this.
As for whether the wound has healed, there is no need to dwell on it; as long as there is no pain or significant bleeding, it should be fine.

7.
Given that you have undergone multiple surgeries on your anus, I personally would not recommend further surgical intervention.
Additionally, fistula surgery inherently damages some of the sphincter muscles, and unless there is a significantly high anal pressure, performing another sphincterotomy does carry risks.

Reply Date: 2019/05/14

More Info

Post-surgery concerns, especially after procedures related to hemorrhoids and anal fissures, can be quite complex and require careful consideration. Based on your detailed description, it seems you have undergone multiple surgeries and are experiencing ongoing issues. Let’s address your questions systematically.

1. Anal Fissures and Visualization During Anesthesia: It is possible that during general anesthesia, the anal sphincter muscles relax significantly, which may make it difficult for a physician to visually confirm the presence of an anal fissure. However, if a fissure is present, it may not necessarily "open up" completely to be visible during a procedure. The absence of a visual diagnosis does not rule out the possibility of a fissure, especially if you continue to experience bleeding during bowel movements.

2. Seeking a Second Opinion: If you are uncomfortable with the current treatment plan and feel that your concerns are not being adequately addressed, it is entirely appropriate to seek a second opinion. You can consult with a trusted physician from B hospital or another specialist in colorectal surgery. Given that it has been two months post-surgery and you are still experiencing symptoms, further evaluation through a digital rectal exam or anoscopy may be warranted.

3. Use of Suppositories: The use of suppositories like Faktu for a month is generally acceptable, but it is crucial to monitor your symptoms closely. If you notice no improvement after a couple of weeks, it would be wise to discuss alternative treatments with your physician. Prolonged use of any medication, including suppositories, can lead to irritation of the anal mucosa, so it's essential to balance treatment with rest for the area.

4. Sitz Bath Temperature: Sitz baths can be beneficial for promoting healing and comfort. The recommended temperature is typically warm but not hot enough to cause discomfort or burns. A temperature around 37-40 degrees Celsius (98.6-104 degrees Fahrenheit) is often suggested. If you find that 42 degrees feels comfortable, ensure it does not cause any pain or discomfort. Sitz baths can be done for about 15-20 minutes, which can help relax the anal muscles and improve blood flow to the area, aiding in healing.

5. Physical Activities Post-Surgery: Activities such as kneeling or sitting cross-legged should be approached with caution. If these positions cause discomfort or strain on the anal area, it may be best to avoid them until you have fully healed. Listening to your body is crucial during recovery.

6. Bowel Movements and Softening Agents: If you are having regular bowel movements without pain, it may not be necessary to continue using softening agents. However, if you notice any straining or discomfort, it may be beneficial to resume them. If the wound does not heal properly, it is advisable to consult your physician sooner rather than later.

7. Surgical Options for Chronic Fissures: If you have persistent symptoms and a confirmed diagnosis of a chronic anal fissure, surgical options such as lateral internal sphincterotomy may be considered. This procedure can relieve tension in the anal sphincter and promote healing. While there is a risk of incontinence, particularly if the procedure is not performed correctly, many patients experience significant relief from symptoms and improved quality of life.

In conclusion, your ongoing symptoms warrant further investigation and possibly a change in your treatment approach. It is essential to communicate openly with your healthcare providers about your concerns and consider seeking a second opinion if you feel your needs are not being met. Your comfort and healing should be the priority, and there are various options available to address your situation effectively.

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