Anal Fissures: Challenges and Treatment Options

Anal issues

Hello Doctor, I inquired at the beginning of January about a situation that has been ongoing since last summer (it's been a whole year!).
Due to an anal fissure, I used ointments, sitz baths, and suppositories.
By October of last year, I developed a dermatitis from the ointment, so I stopped all treatments and kept the area dry for a week.
After that, a crack appeared on the skin around the anus and perineum.
I went to the emergency room for pain relief, but it was ineffective.
I endured severe pain and difficulty walking, so I took a taxi to a teaching hospital.
The doctor there said the external wound couldn't be stitched, and prescribed zinc oxide ointment.
After more than ten days, it healed, but I still couldn't walk or sit comfortably due to the perineal scar.
I then visited a dermatologist to address the dermatitis, but the internal wound was also slow to heal, and passing soft stools was painful.
After sitz baths, I had to apply lotion to walk slowly.
I returned for follow-ups, receiving more suppositories and sitz baths, but defecation remained painful! My mobility has been limited; I can only take a taxi to the hospital, and during wait times, I can only stand.
Walking causes pain from the friction of the perineal skin, and sitting causes pressure pain.
For over six months, this pain has left me feeling helpless, unable to engage in any activities, and I often need family assistance.
Recently, I returned to the hospital to ask the doctor about surgical treatment.
The doctor said that since the skin has healed, surgery is unnecessary, and he had no solutions for my mobility issues.
I was advised to continue applying lotion and to keep using sitz baths and suppositories for the internal wound.
A few days ago, I tried to walk a bit more, but the friction caused a burning sensation and increased pain (without any visible wounds).
When showering, the water pressure and drying caused the healed skin to contract painfully towards the midline, so I had to apply more lotion.
Eventually, I stopped using suppositories and sitz baths because they had no effect over the year and instead worsened my condition.
I have spent considerable time and money trying various treatments with little progress, and I don't want to repeat last year's situation.
For more than six months, I have been at the same teaching hospital and have visited other hospitals, all of which prescribed suppositories and sitz baths.
It seems impossible to return to normal mobility; I have had to get used to this constant pain.
The hospitals I visited said that pulling and friction wouldn't cause further injury, so I have resigned myself to the pain, enduring discomfort from both the internal and external wounds.
Sometimes, I feel like the internal and external wounds are pulling against each other.
I have tried applying zinc oxide again, but it led to dryness and further difficulty walking, leaving me feeling very helpless.
I still hope for a chance to recover, so I wonder if it's true, as the hospitals say, that "surgery is not possible for the external skin?" Am I destined to repeat the original treatment of suppositories and sitz baths for the internal wound without needing extensive surgery? After the perineal skin heals, I also wonder if surgical treatment is an option.
Even for typical hemorrhoid suturing, it seems unlikely that this area would be addressed, which is truly disheartening.

Yǔ wàijiè géjué de rén, 40~49 year old female. Ask Date: 2023/05/28

Dr. Ke Fangxu reply Surgery

If the pain from an anal fissure is severe, surgical treatment may be considered.
If there is also increased pressure in the anal sphincter, a sphincterotomy may be necessary.
However, I have encountered cases where anal pain was actually caused by nerve pain due to a herniated disc.
It is advisable to confirm the diagnosis before proceeding with surgical treatment.

Reply Date: 2023/05/28

More Info

Anal fissures are a common yet often distressing condition that can significantly impact a person's quality of life. They are small tears in the lining of the anal canal, typically caused by trauma during bowel movements, particularly when passing hard stools. Your experience over the past year highlights the challenges many face when dealing with this condition, especially when conservative treatments fail to provide relief.

From your description, it seems that you have been through a comprehensive treatment regimen, including topical medications, sitz baths, and suppositories. While these treatments are often effective for many patients, they can sometimes lead to complications, such as skin irritation or dermatitis, as you've experienced. This can create a cycle of discomfort that complicates healing.

The fact that you have developed a skin condition due to the topical treatments indicates that your skin may be particularly sensitive or reactive. This is not uncommon, and it can make managing anal fissures more challenging. The pain you describe, especially during movement and sitting, suggests that the fissure may not be healing properly, possibly due to ongoing irritation or tension in the area.

In terms of treatment options, there are several avenues to consider:
1. Dietary Modifications: Ensuring a diet high in fiber can help soften stools and reduce strain during bowel movements. Staying well-hydrated is also crucial. Sometimes, a stool softener or a mild laxative can be beneficial.

2. Topical Treatments: While you've tried various topical treatments, it may be worth discussing with your healthcare provider the possibility of using a topical nitroglycerin ointment or calcium channel blockers, which can help relax the anal sphincter and promote healing.

3. Botulinum Toxin Injections: In cases where conservative treatments fail, botulinum toxin injections can be considered. This treatment works by temporarily paralyzing the anal sphincter muscle, reducing spasm and allowing the fissure to heal.

4. Surgical Options: If the fissure is chronic and does not respond to conservative treatments, surgical intervention may be necessary. The most common procedure is lateral internal sphincterotomy, which involves cutting a small portion of the anal sphincter muscle to relieve tension and promote healing. While you mentioned that your doctor suggested surgery might not be necessary since the skin has healed, it is essential to have a thorough discussion about your ongoing symptoms and the potential benefits of surgery.

5. Physical Therapy: Some patients find relief through pelvic floor physical therapy, which can help address any muscle tension or dysfunction contributing to pain and discomfort.

6. Pain Management: Since you are experiencing significant pain, discussing pain management strategies with your healthcare provider is essential. This may include medications or alternative therapies to help manage your discomfort.

It's crucial to maintain open communication with your healthcare provider about your symptoms and treatment progress. If you feel that your current treatment plan is not effective, seeking a second opinion or consulting a specialist in colorectal surgery may provide additional insights and options.

In summary, while anal fissures can be challenging to treat, various options are available. It may take time to find the right combination of treatments that work for you. Your persistence in seeking help is commendable, and I encourage you to continue advocating for your health and exploring all available options to find relief and restore your quality of life.

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