Anal Fissures: Symptoms, Treatments, and Surgical Options

Anal fissure issues (continued)

Hello Dr.
Ke: Thank you for taking the time to respond on May 1st.
After visiting another clinic, I realized that the wound on the right posterior side is about one centimeter inside the anal area, which is not a large wound.
Therefore, after using suppositories and sitz baths for a few months, it seems there hasn't been much improvement.
The suppositories tend to move inward with contractions, and when I switched to another type, it melted and became very oily, causing my underwear to become greasy when I pass gas.
Due to the oiliness, my bowel movements the next morning feel very watery, which increases the pain and frequency (I usually eat a lot of vegetables and fruits).
I had to revert to my original suppository.
During the recent examination with the anoscope, I could clearly feel the wound, which helped the doctor understand that it is not as deep as initially thought.
However, after touching the wound, the surrounding muscles also started to hurt! After the consultation, while the wound continued to hurt, the surrounding muscles felt less painful.
After returning home, I noticed a significant urge to defecate due to the irritation from the wound, but after soaking, the urge diminished.
Previously, when I visited my original hospital, they mentioned that last year's wound was deeper, but it has healed.
A few months ago, I felt that the previous wound was still present, but after using suppositories and sitz baths, I gradually felt that the wound is not as deep.
So now, I wonder if this has become chronic? (Last year it took over a month to heal, and this time it has been several months with no improvement.) I am unsure how to manage sitz baths now.
Soaking provides a lot of relief, but afterward, when the contractions occur, water can touch the wound, causing discomfort and pain (the water temperature has been confirmed to not be too high).
The hospital advised that after using the restroom, soaking for a few minutes is sufficient, and if it’s not too painful, I shouldn’t force myself to soak, as water touching the wound can also irritate it.
Should I keep my anal muscles tightly contracted during other soaking times? I don’t understand why the pain medication and muscle relaxants have no effect; I feel discomfort and pain all day long, and sitting puts pressure on the wound.
Since the wound is located on the right posterior side and not very deep, using a donut cushion still puts pressure on the surrounding muscles, causing pain within two minutes.
By the end of the day, I also develop a headache, which the pain medication alleviates.
Should I avoid sitting to prevent pressure on the wound to avoid irritation? After using the restroom in the morning and soaking a bit, I confirmed that I had no urge to defecate.
However, if I feel a significant urge shortly after, I still manage to pass a small amount (very little).
So, if I feel the urge, can I soak again to alleviate the urge? I’m worried that water touching the wound will cause pain, which feels contradictory.
During the day, I drink a lot of water, but it seems I have little urge to urinate, and the frequency has decreased significantly.
When I do soak, I feel a strong urge to urinate within a minute.
If I don’t soak during the day, I usually urinate more frequently after dinner until bedtime.
I mentioned this during my consultation, but the doctor didn’t comment.
Currently, I can only rest at home and am hesitant to sit, making it impossible to return to work! During the day, when I lie down to rest, even the pressure from the bed on my buttocks is uncomfortable, so I have to lie on my side, stand, or walk a little.
It has been very difficult to sleep well for a long time, and I can only eat while sitting on the sofa or standing.
Since I previously had an allergic reaction to topical medications, I am now completely afraid to apply anything.
The wound is not very deep; would surgery help? I also have three grade II internal hemorrhoids.
I have seen others’ questions, and if surgery is performed, will those be addressed as well? I recall that if internal hemorrhoids are surgically removed, the anus needs to be sutured, or can the internal hemorrhoids be left untreated? I really don’t want to switch medications and apply ointments, as I am very prone to allergies with Neomycin ointment.
I genuinely want to resolve this issue completely, but even one wound can cause discomfort all day long; having more wounds from surgery would likely be even more painful! I have asked doctors at the hospital, and they do not recommend surgery, stating that given my condition, surgery could lead to complications.
A nurse at a clinic once mentioned that if my stool is thicker than my thumb, it could be too large, which prevents the wound from healing.
I consistently have stools thicker than my thumb, and everyone I ask, including family and friends, says it must be thicker than that.
Currently, I can only avoid eating too much to prevent having to go two or three times! Is it possible for an anal fissure to develop into a fistula? (Considering my type of wound) If surgery is performed, could the additional wounds lead to a fistula? Thank you!

TED, 50~59 year old female. Ask Date: 2023/05/03

Dr. Ke Fangxu reply Surgery

1.
Symptoms that persist for more than one month are considered chronic.

2.
Sitz baths are recommended 3-4 times a day for 15 minutes each time, with water temperature not exceeding 36-38 degrees Celsius.
If discomfort occurs after the bath, a topical ointment can be applied.

3.
Pain from anal fissures is unavoidable; using a soft cushion can help alleviate discomfort.

4.
It is possible to have bowel movements, but frequent defecation is still not recommended.

5.
During anal fissure surgery, if hemorrhoids are detected, they are typically removed at the same time.
If you prefer not to have hemorrhoid removal, you should inform your physician in advance.

6.
Anal fissures and fistulas are different conditions, and surgery will not cause the surgical site to develop into a fistula.

Reply Date: 2023/05/03

More Info

Anal fissures are small tears in the lining of the anus, often causing significant pain and discomfort during bowel movements. They can be acute (recently developed) or chronic (lasting more than six weeks). Understanding the symptoms, treatments, and surgical options available for anal fissures is crucial for effective management.

Symptoms of Anal Fissures
The primary symptom of an anal fissure is pain during and after bowel movements, which can be severe and may last for hours. Other symptoms include:
- Bright red blood on the stool or toilet paper.

- A visible tear or crack in the skin around the anus.

- Itching or irritation around the anal area.

- A spasm of the anal sphincter muscle, which can exacerbate pain.

In your case, it seems that the fissure has been persistent, causing ongoing discomfort and affecting your daily activities. The pain you experience, especially after bowel movements, is typical for chronic fissures. The fact that you have tried various treatments, including suppositories and sitz baths, indicates that you are actively seeking relief.

Treatment Options
1. Conservative Treatments:
- Dietary Changes: Increasing fiber intake can help soften stools and reduce straining during bowel movements. This is essential, as straining can worsen fissures.

- Hydration: Drinking plenty of water can also help maintain stool softness.

- Sitz Baths: Soaking in warm water can help relax the anal muscles and promote healing. However, as you mentioned, if water irritates the fissure, it may be best to limit the duration of the baths or avoid them altogether.

- Topical Treatments: Nitroglycerin ointment or calcium channel blockers can help relax the anal sphincter and promote healing. However, you should avoid any medications that you have previously had allergic reactions to.

2. Medications:
- Pain relief medications can help manage discomfort, but if they are not effective, it may be necessary to consult your doctor for alternatives.

- Muscle relaxants may also be prescribed to alleviate spasms.

3. Surgical Options:
- If conservative treatments fail after several months, surgical intervention may be considered. The most common procedure is lateral internal sphincterotomy, which involves cutting a small portion of the anal sphincter muscle to reduce tension and pain, allowing the fissure to heal.

- Surgery can be effective, but it does carry risks, including potential complications such as incontinence or the formation of a fistula (an abnormal connection between the anal canal and the skin).

Risks and Considerations
- Chronicity: Chronic fissures can lead to complications such as anal abscesses or fistulas. If your fissure has been present for several months, it is essential to monitor for any signs of infection or worsening symptoms.

- Internal Hemorrhoids: You mentioned having internal hemorrhoids. If surgery is performed, the surgeon may address both the fissure and the hemorrhoids simultaneously. However, this decision should be made based on a thorough evaluation of your condition.

- Post-Surgical Recovery: While surgery can provide relief, recovery may involve some discomfort, and it is essential to follow post-operative care instructions to minimize complications.

Conclusion
Given your ongoing symptoms and the impact on your quality of life, it is advisable to consult a colorectal surgeon who specializes in anal disorders. They can provide a comprehensive evaluation and discuss the potential benefits and risks of surgical intervention. Additionally, addressing any underlying issues, such as dietary habits and bowel habits, is crucial for long-term management. If you continue to experience significant pain and discomfort, do not hesitate to seek further medical advice.

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