Hemorrhoids and Anal Fissures: Surgical Options and Relief

Hemorrhoid surgery and anal fissure issues?

Hello, doctor.
Over five months ago, I experienced constipation and hard stools for two consecutive weeks.
After wiping, I noticed excessive bleeding and itching, which led me to seek medical attention.
I was informed for the first time that I had both internal and external hemorrhoids and anal fissures.
The doctor suggested ligating the three internal hemorrhoids with rubber bands and then undergoing electrosurgery to remove the external hemorrhoids on the same day.
At that time, I did not proceed with the ligation and only used topical medication.
For the past four months, I have occasionally used the High Xylmol Ointment prescribed by the doctor, and although the itching after bowel movements has been tolerable, I did not engage in extensive care.
However, in the past month, I have frequently experienced sudden, intense itching, pain, and discomfort around the anal area, sometimes making it difficult to sit or concentrate.
Additionally, there has been bleeding after each bowel movement, with some blood at the end of the stool and significant blood on the toilet paper during wiping.
After consulting another colorectal specialist, I was informed that the anal fissure is still present, and while the external hemorrhoid is not large (it has no thrombosis but is about the size of two-thirds of a raisin and is difficult to push back in, located near the perineum), the doctor advised that it does not need to be surgically removed.
He prescribed Flucort F Ointment (Fluocinolone and Fradiomycin) and Xylmol for me to use as a suppository.

After applying Flucort F, I noticed reduced itching around the anus, but any pressure on the external hemorrhoid still causes pain.
Additionally, if I stay up late or do not have a bowel movement that day, the next day I experience severe itching and pain.

I would like to ask the following questions:
1.
Could my intermittent itching and pain be caused by the external hemorrhoids or the anal fissure?
2.
I still notice a significant amount of blood on the toilet paper after wiping post-bowel movement.
Is this due to the stool pulling on the internal fissure or the internal and external hemorrhoids? The only issues affecting me are the bleeding and pain when the external hemorrhoid is touched or when I try to push it back in.
Is it possible to only remove the external hemorrhoid without ligating the internal hemorrhoids?
3.
What is your opinion on the electrosurgical removal of external hemorrhoids in the outpatient setting? Will it effectively resolve my intermittent itching and pain throughout the day? Will the surgery have irreversible effects on the skin around the anus? Will the shape and function of the anus remain intact post-surgery, similar to when the external hemorrhoid was not prolapsed? The second doctor mentioned that using medication is sufficient for the symptoms, and while the external hemorrhoid is not large and the internal hemorrhoids are also relatively small, I would consider surgery if it could provide long-term relief from my discomfort.
However, I want to ensure that the benefits outweigh the risks, as I consistently experience pain, itching, and bleeding when touching the external hemorrhoid and perineal area after each bowel movement.
Please advise on the appropriate course of action.
Thank you.

Ahao, 30~39 year old female. Ask Date: 2021/07/02

Dr. Ke Fangxu reply Surgery

1.
Both external hemorrhoids and anal fissures can cause itching, but pain is mostly caused by anal fissures.

2.
The amount of bleeding from an anal fissure is generally minimal; if there is significant bleeding, the likelihood of hemorrhoidal bleeding is greater.
If only external hemorrhoids are excised, the bleeding issue may not necessarily improve.

3.
Personally, I do not perform external hemorrhoid excision surgeries in the clinic, so I cannot provide clinical experience on whether it can improve symptoms.
As for what is meant by "irreversible effects," I do not understand.

Reply Date: 2021/07/02

More Info

Understanding hemorrhoids and anal fissures is crucial for effective management and relief. Based on your description, it seems you are experiencing symptoms related to both external hemorrhoids and anal fissures, which can indeed cause significant discomfort, pain, and bleeding.

1. Causes of Pain and Itching: The pain and itching you are experiencing could be attributed to both external hemorrhoids and anal fissures. External hemorrhoids can become thrombosed (clotted), leading to severe pain, especially when sitting or during bowel movements. Anal fissures, on the other hand, are small tears in the lining of the anus, often caused by passing hard stools. The irritation from the fissure can lead to spasms of the anal sphincter, which can exacerbate pain and discomfort. Given that you have experienced significant pain and bleeding, it is likely that both conditions are contributing to your symptoms.

2. Bleeding After Bowel Movements: The bleeding you notice on toilet paper after wiping is commonly associated with anal fissures and external hemorrhoids. When hard stools pass through the anal canal, they can irritate or tear the sensitive tissue, leading to bleeding. If the external hemorrhoid is inflamed or irritated, it can also contribute to bleeding. It is essential to address both issues to achieve relief. While it may be tempting to only remove the external hemorrhoid, if the internal hemorrhoids are also contributing to your symptoms, they may need to be addressed as well.

3. Surgical Options: Regarding the surgical options, the use of a rubber band ligation for internal hemorrhoids is a common and effective treatment. It can help reduce the size of the internal hemorrhoids, which may alleviate some of the pressure and discomfort you are experiencing. The external hemorrhoid can be removed using a procedure called hemorrhoidectomy, which can provide significant relief from pain and discomfort.
When considering surgical intervention, it is essential to weigh the benefits against the risks. A hemorrhoidectomy can effectively resolve symptoms, but it may also lead to temporary discomfort and changes in the anal area. However, most patients find that the long-term benefits of pain relief and improved quality of life outweigh the initial discomfort.
Post-surgery, the anal area should maintain its shape and function, although some patients may experience changes in sensation or minor adjustments in bowel habits. It is crucial to follow your surgeon's post-operative care instructions to promote healing and minimize complications.

In conclusion, it seems that a combination of treatments may be necessary to address your symptoms effectively. This could include managing your diet to prevent constipation, using topical treatments as prescribed, and considering surgical options for both the external and internal hemorrhoids. Consulting with a colorectal surgeon can provide you with a tailored approach based on your specific situation, ensuring that you receive the most appropriate care for your symptoms. Remember, timely intervention can lead to significant relief and improve your quality of life.

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