Anal Fissures: Symptoms, Treatments, and Concerns

Regarding anal fissures?

Hello Dr.
Ke,
Three months ago, after a natural delivery, I experienced intermittent diarrhea for a period of time, which led me to delay seeking medical attention.
After the diarrhea, I noticed some discharge from my anus that was greenish in color.
I first visited a gynecologist, who indicated that the discharge was not from the perineum and prescribed antibiotics, along with a bacterial culture that revealed Escherichia coli.
Due to a small lump near my anus that resembled a pimple, I consulted a colorectal specialist.
The doctor examined my anus and perineum (suspecting that my pain was due to childbirth) and informed me that I have a severe anal fissure.
I was prescribed a topical medication and advised to take warm sitz baths (though I haven't been very diligent about it).

Now, a month has passed since my last appointment, and I still experience pain when pressing on the right side of my anus.
When I have a bowel movement, if the stool is formed, I feel a slight stinging pain at the front, and there is a bit of moisture on the toilet paper when I wipe, but it disappears after a couple of wipes.
There is no blood in my stool.
My current symptoms are as follows:
1.
When I exert some effort during a bowel movement, the skin around my anus experiences slight stinging, and wiping may result in a little blood.
2.
Pressing around the area during cleansing also causes pain.
3.
During anal contractions, it feels like there is something at the anal opening.
4.
I do not experience pain while sitting or sleeping.
5.
Does the topical medication need to be inserted into the anus? (The doctor only instructed me to apply it where it hurts.) The lump has disappeared, but pressing around it still causes pain.
6.
Recently, I have noticed increased pain around my anus when applying the topical medication and intensifying the warm sitz baths.
Could this lead to increased discharge from the perineum? The discharge has increased recently.
7.
The perineal area still hurts; could this be due to an infection from the E.
coli?
8.
In late September, I returned to the gynecologist, who said the wound looked good, but I am still experiencing pain.
9.
Besides the topical medication, are there other ointments available? (I believe the current one is typically used for hemorrhoids.)
Thank you.

AA, 30~39 year old female. Ask Date: 2011/11/03

Dr. Ke Fangxu reply Surgery

Based on your description, it seems more like an anal fissure; however, the diarrhea after childbirth could also lead to an infection of the perineal wound.
The Pingzhi Long ointment can be applied internally into the anus, but it is generally recommended to use suppositories for safety.
Medications applied at the anal area primarily serve to relieve pain and reduce inflammation, so there should be no issues with their use.
I suggest you visit a colorectal surgery clinic for a detailed examination to check for any issues beyond the anal fissure.

Reply Date: 2011/11/03

More Info

Anal fissures are small tears in the lining of the anus, often resulting from trauma, such as passing hard stools or prolonged diarrhea. They can cause significant discomfort and pain, particularly during bowel movements. Given your situation, it seems that your anal fissure may have developed as a result of the diarrhea you experienced postpartum, and it has persisted despite treatment.

Symptoms of Anal Fissures
From your description, it appears you are experiencing several common symptoms associated with anal fissures:
1. Pain during bowel movements: You mentioned that when you exert some effort during defecation, you feel a sharp pain around the anal area, which is typical for fissures.

2. Bleeding: The presence of a small amount of blood on the toilet paper after wiping is also a common symptom. This usually occurs due to the fissure being irritated during the passage of stool.

3. Discomfort during cleaning: Pain when pressing around the anal area during cleaning can indicate that the fissure is still inflamed or that there may be some irritation in the surrounding tissue.

4. Sensation of fullness: The feeling of having something at the anal opening during anal contraction can be due to the fissure or associated muscle spasms.

Treatment Options
The treatment for anal fissures typically includes:
- Topical medications: You mentioned using a medication called "平痣隆" (likely referring to a topical anesthetic or steroid cream). This can help reduce pain and inflammation. It is generally applied externally, but some formulations may be inserted into the anal canal for better effect. You should follow your doctor's instructions regarding application.

- Warm sitz baths: These can help soothe the area and promote healing. Regular sitz baths can be beneficial, especially after bowel movements.

- Dietary changes: Increasing fiber intake and hydration can help soften stools, making bowel movements less painful and reducing strain.

- Laxatives: If dietary changes are insufficient, your doctor may recommend a stool softener or laxative to ease bowel movements.

Concerns and Follow-Up
1. Increased Discharge: If you notice an increase in discharge, it could be due to irritation or infection. It’s essential to monitor this and discuss it with your healthcare provider.

2. Persistent Pain: If the pain continues despite treatment, it may indicate that the fissure has not healed properly or that there are other underlying issues, such as an infection or another condition affecting the anal area.

3. Follow-Up Appointments: It’s crucial to keep your follow-up appointments with your healthcare provider. They can assess the healing process and determine if further intervention is necessary, such as additional medications or, in some cases, surgical options if conservative treatments fail.

Additional Medications
If "平痣隆" is not providing sufficient relief, you might inquire about other topical treatments. Options may include:
- Nitroglycerin ointment: This can help relax the anal sphincter and increase blood flow to the area, promoting healing.

- Calcium channel blockers: Topical formulations can also help with relaxation and healing.

- Botulinum toxin injections: In some cases, this may be considered to relieve sphincter spasms.

Conclusion
Anal fissures can be quite painful and may take time to heal, especially if there are contributing factors like ongoing diarrhea or straining during bowel movements. It’s essential to maintain communication with your healthcare provider, adhere to treatment recommendations, and report any changes in symptoms. If you have further concerns or if symptoms worsen, do not hesitate to seek medical attention sooner rather than later.

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