Anal Fissures: Causes, Treatment, and Concerns

Please inquire about anal fissure issues?

Hello Dr.
Ke: I have maintained a relatively stable bowel habit, with normal stool quality and frequency.
However, in February of this year, I experienced a more severe episode of hard stool (after not having a bowel movement for two days), which led to an anal fissure that took three days to heal (I managed this with Normacol Plus and applying Proctosedyl).
The doctor who examined me said I only had an anal fissure and no hemorrhoids.
I have a few questions to ask you:
1.
Since that incident, I have been taking Normacol Plus regularly, almost every day, controlling the dosage to about half to one packet daily.
I have tried stopping the medication, but within a day or two, the stool becomes slightly hard again, leading to bleeding from the fissure (prior to this year, slightly hard stools did not cause fissures).
I am concerned about the 8% laxative component in the medication, fearing it may cause dependency, although the doctor mentioned that the amount is mild and that the other components are mostly cellulose.
What is your opinion on this? Are there other alternatives for long-term use? (I have been very mindful of my diet and fluid intake.)
2.
Recently, I tried going four days without the medication, but this resulted in another severe episode of hard stool and bleeding from the fissure.
This time, the treatment has lasted almost a week without healing (the bowel movement process still involves sharp pain, burning sensation, and a small amount of blood during wiping).
Previously, I would recover within a day of treatment.
Does this indicate that the wound has worsened, or has it become a chronic fissure? Do I need further examination or treatment? If surgery is necessary, what would that typically involve?
3.
Can repeated anal fissures gradually evolve into hemorrhoids or fistulas?
4.
Can anal fissures lead to urinary issues?
Thank you once again for your willingness to patiently address everyone's concerns.
I appreciate it!

Youxinren..., 30~39 year old female. Ask Date: 2013/10/10

Dr. Ke Fangxu reply Surgery

1.
The reason Normacol plus has "plus" in its name is that it contains a small amount of a stool softener.
Initially, a version of Normacol without the stool softener was introduced, but the National Health Insurance Administration deemed that without any medicinal ingredients, it could only be sold as a food product.
This is why only Normacol plus is available in hospitals.
The stool softener is mild and low in dosage, as your physician mentioned, so it is not a concern.
If you prefer not to take a stool softener, consuming a large amount of fiber is also an option.
Food-grade fiber supplements should be available at pharmacies or health food stores.
2.
Based on your description, it is likely a case of chronic anal fissure.
In addition to regular medication and frequent sitz baths, surgery may be the only option.
The surgery not only involves excising the fissure but also performing a sphincterotomy to relieve the pressure from anal sphincter contraction.
3.
No, but it is possible for hemorrhoids to worsen due to constipation.
4.
Anal fissures can indeed affect urination due to pain, as the pain can create a psychological fear that impacts urinary control.
If the situation is severe, it may be beneficial to use medications from a urologist in conjunction with treatment.

Reply Date: 2013/10/10

More Info

Anal fissures are small tears in the lining of the anus, often caused by passing hard or large stools. They can be quite painful and may lead to bleeding during bowel movements. Your experience with anal fissures, particularly following an episode of hard stool, is not uncommon. Let's address your concerns one by one.

1. Long-term Use of Normacol Plus: Normacol Plus contains a combination of fiber and a mild laxative (sodium picosulfate). While the fiber component is beneficial for maintaining stool consistency and preventing constipation, the laxative effect can lead to dependency if used excessively. However, as your doctor mentioned, the amount of laxative in Normacol Plus is relatively low and is generally considered safe for long-term use. If you are concerned about dependency, consider gradually reducing your dosage while increasing your intake of natural fiber through diet (fruits, vegetables, whole grains) and ensuring adequate hydration. You might also explore other fiber supplements that do not contain laxatives, such as psyllium husk or methylcellulose.

2. Recurrence of Hard Stools and Fissures: The recurrence of hard stools and subsequent fissures may indicate that your bowel habits are not fully optimized. If you have been experiencing pain and bleeding for a week without improvement, it is possible that the fissure has become chronic. Chronic fissures can take longer to heal and may require more intensive treatment. If you notice persistent symptoms, it would be wise to consult a healthcare provider for a thorough examination. They may recommend topical treatments, such as nitroglycerin ointment or calcium channel blockers, which can help relax the anal sphincter and promote healing. In some cases, surgical intervention may be necessary, particularly if conservative treatments fail. This could involve a procedure called lateral internal sphincterotomy, which helps to relieve tension in the anal sphincter.

3. Risk of Developing Fistulas or Abscesses: Recurrent anal fissures can lead to complications such as anal fistulas or abscesses, although this is not common. A fistula is an abnormal connection between the anal canal and the skin, which can develop if a fissure does not heal properly. If you experience symptoms such as persistent pain, swelling, or discharge, it is essential to seek medical attention.

4. Impact on Urination: Generally, anal fissures do not directly affect urination. However, the pain associated with fissures may cause discomfort during bowel movements, which can lead to anxiety about defecation. This anxiety may indirectly affect your overall pelvic floor function, but it should not cause urinary problems. If you experience any urinary symptoms, such as pain during urination or changes in urinary frequency, it would be advisable to discuss these with your healthcare provider.

In summary, managing anal fissures involves a combination of dietary changes, proper hydration, and possibly the use of topical treatments. If your symptoms persist or worsen, further evaluation and treatment may be necessary. It’s important to communicate openly with your healthcare provider about your concerns and treatment options. They can help guide you toward the most effective management strategies for your situation.

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