Anal Fissures and Mixed Hemorrhoids: Symptoms and Treatment Options

Anal fissure, mixed hemorrhoids?

Hello Dr.
Ke,
I apologize for the disturbance.
I have issues with internal hemorrhoids and mixed hemorrhoids.
Previously, I had internal hemorrhoids that bled, so I underwent rubber band ligation treatment about 3-4 times.
One of the hemorrhoids is mixed, and the doctor mentioned that it is inverted.
He could only perform rubber band ligation on the internal part, while the external part that is inverted cannot be treated without surgery, so I was advised to coexist with it peacefully.
Initially, I planned to coexist with it, although it was quite bothersome (as the hemorrhoids would protrude during bowel movements and I had to push them back manually), but I thought I could get used to it.
However, about two weeks ago, I noticed blood on the toilet paper after a bowel movement.
At first, I thought it might just be a flare-up of the hemorrhoids, so I ignored it for the first two days.
By the third or fourth day, I suddenly felt a tearing pain in my anus after a bowel movement, and there was quite a bit of bleeding.
I quickly went to see a doctor, thinking I might have developed another internal hemorrhoid that would require rubber band ligation again.
To my surprise, the doctor informed me that I had an anal fissure, possibly caused by hard stools or diarrhea.
He prescribed a hemorrhoid suppository and a topical ointment for hemorrhoids, instructing me to use the suppository once in the morning, along with anti-inflammatory, pain relief, hemostatic, anti-swelling, stool softening medications, and warm sitz baths.
I have been diligently following the treatment since my visit on August 30, and I have returned for follow-ups three times, but there has been no improvement.
During my last visit on September 6, the doctor noted that my bleeding and pain had not improved and suggested considering surgery, explaining that the procedure would take about 15 minutes under local anesthesia, and I would need to soak in water at home for three days post-operation, with a healing time of about three weeks.
I would like to ask Dr.
Ke:
1.
I experience bleeding immediately during bowel movements, and I can feel the hemorrhoids protruding, which causes a stinging pain as they pass through the anus.
I know I have an anal fissure, but the amount of blood is quite significant, similar to menstrual flow, bright red, and the toilet is filled with blood.
Is it possible for an anal fissure to cause this much bleeding, or is most of the blood actually from the hemorrhoids, with the fissure just coinciding? I find it quite frightening since bleeding only occurs during bowel movements and not otherwise.
2.
During my last visit on September 6, I wanted the doctor to check the condition of the anal fissure to understand why the bleeding had increased and why there was no improvement.
However, the doctor refrained from examining the fissure, fearing that it might cause further tearing or pain.
At that time, I wanted to know if the significant bleeding was due to the fissure or if it was caused by the internal hemorrhoids.
If the bleeding is primarily due to the internal hemorrhoids, could it be possible to simply ligate the bleeding hemorrhoid without needing surgery?
3.
On two occasions during bowel movements, I noticed small clots resembling menstrual blood.
Is this due to bleeding and the use of hemostatic medication causing the blood to clot? However, this only happened twice, and since then, I have only experienced bright red blood.
4.
I have been using the suppository, ointment, hemostatic, anti-swelling, and pain relief medications for nearly two weeks.
Is it safe to use these medications continuously for such a long time? Additionally, my menstrual period is approaching in a few days; are these medications still appropriate to use, especially the hemostatic medication?
5.
Currently, I do not experience bleeding or anal pain unless I have a bowel movement, but there is a slight swelling sensation in the anus (similar to the swelling felt after rubber band ligation).
Is this normal?
6.
I have noticed that my hemorrhoid issues seem to flare up particularly before my menstrual period or around ovulation.
Is there a connection between these two occurrences?
7.
The doctor suggested considering surgery due to my anal fissure combined with hemorrhoids, which keeps protruding and causing repeated tearing, making it difficult for the fissure to heal.
Would you also recommend surgery, Dr.
Ke? If surgery is not the only option, are there other possible treatments? The doctor did not specify what type of surgery it would be, only that it would take about 15 minutes under local anesthesia, and I would need to soak in water for three days post-surgery, with a healing time of approximately three weeks.
8.
Since my first visit on August 30, I have been bleeding at least twice daily, as bleeding occurs with every bowel movement, and the amount of blood is similar to menstrual flow.
If this continues, am I at risk of anemia or excessive blood loss? (Seeing blood in the toilet is quite frightening.)
Thank you, Dr.
Ke, for your patience in reading this.
Thank you.

Xin Yu, 30~39 year old female. Ask Date: 2021/09/10

Dr. Ke Fangxu reply Surgery

1.
It is possible that the larger amount of bleeding is due to a combination of anal fissures and hemorrhoids.

2.
According to health insurance regulations, a patient can only undergo ligation four times a year; if it exceeds four times, further procedures cannot be performed.
Additionally, ligation is not recommended if accompanied by anal fissures, as it may lead to more severe pain.

3.
It is possible.

4.
Menstruation does not affect the condition, but the amount of bleeding may decrease.

5.
Yes.

6.
Indeed, some patients experience hemorrhoidal bleeding around their menstrual periods for unknown reasons.

7.
Hemorrhoidal prolapse is indeed better treated with surgery; however, I personally do not perform local anesthesia surgeries, so I cannot comment on that.

8.
Most patients do not have anemia; a blood test is necessary to confirm.

Reply Date: 2021/09/10

More Info

Anal fissures and mixed hemorrhoids are common conditions that can cause significant discomfort and distress. Understanding their symptoms, causes, and treatment options is essential for effective management.

Symptoms
1. Anal Fissures: These are small tears in the lining of the anus, often resulting from passing hard stools or prolonged diarrhea. Symptoms include:
- Sharp pain during and after bowel movements.

- Bright red blood on toilet paper or in the toilet bowl.

- A visible tear or crack in the anal skin.

- Spasms of the anal sphincter.

2. Mixed Hemorrhoids: These consist of both internal and external hemorrhoids. Symptoms may include:
- Bleeding during bowel movements, which may be bright red.

- Pain or discomfort, especially if external hemorrhoids are thrombosed (clotted).

- A lump near the anus, which may be sensitive or painful.

- Itching or irritation in the anal region.

Causes
- Constipation and Straining: Hard stools can lead to both fissures and hemorrhoids due to excessive straining during bowel movements.

- Diarrhea: Frequent loose stools can irritate the anal area, leading to fissures.

- Pregnancy and Childbirth: Increased pressure on the pelvic region can contribute to hemorrhoids.

- Chronic Conditions: Conditions such as inflammatory bowel disease (IBD) can exacerbate these issues.

Treatment Options
1. Conservative Management:
- Dietary Changes: Increasing fiber intake can help soften stools and reduce straining. Hydration is also crucial.

- Topical Treatments: Creams or ointments containing hydrocortisone can reduce inflammation and pain. Analgesic ointments can also provide relief.

- Sitz Baths: Soaking in warm water can soothe the anal area and promote healing.

2. Medications:
- Laxatives: Over-the-counter laxatives can help maintain soft stools.

- Suppositories: Medications like those you mentioned (e.g., anti-inflammatory or analgesic suppositories) can help manage symptoms.

3. Surgical Options:
- If conservative treatments fail, surgical options may be considered. For fissures, a lateral internal sphincterotomy may be performed to relieve tension in the anal sphincter. For hemorrhoids, procedures like rubber band ligation or hemorrhoidectomy may be necessary.

Addressing Your Concerns
1. Bleeding and Pain: The significant bleeding you describe could be due to either the anal fissure or the hemorrhoids. It’s possible that the fissure is exacerbating the bleeding from the hemorrhoids. A thorough examination by a healthcare provider is essential to determine the source of the bleeding.

2. Medication Duration: The medications you are using can typically be used for a couple of weeks, but it’s essential to follow your doctor’s advice. If you have concerns about prolonged use, especially regarding the hemostatic agents, discuss this with your physician.

3. Blood Clots: The presence of clots can occur if there is significant bleeding and subsequent clotting. This is not uncommon, especially if you have been experiencing heavy bleeding.

4. Surgery Consideration: Given your ongoing symptoms and the impact on your quality of life, discussing surgical options with your doctor may be prudent. Surgery can provide a more permanent solution, especially if conservative measures have not been effective.

5. Anemia Risk: Continuous bleeding can lead to anemia, especially if you are losing significant amounts of blood. Monitoring your hemoglobin levels may be necessary.

6. Hormonal Influence: Hormonal changes during menstruation can affect bowel habits and may exacerbate hemorrhoid symptoms. It’s worth discussing this with your doctor to explore any potential connections.

7. Follow-Up: Regular follow-ups with your healthcare provider are crucial to monitor your condition and adjust treatment as necessary. If symptoms worsen or new symptoms arise, seek medical attention promptly.

In conclusion, while anal fissures and mixed hemorrhoids can be distressing, understanding their symptoms and treatment options can help you manage your condition effectively. Always consult with your healthcare provider for personalized advice and treatment plans tailored to your specific situation.

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