Hemorrhoids vs. Anal Fissures: Pain and Treatment Insights

Hemorrhoids or anal fissure?

I previously sought medical attention due to severe pain during bowel movements, which the doctor diagnosed as hemorrhoids rather than anal fissures.
I underwent rubber band ligation.
After the procedure, I experienced some improvement, but almost every three weeks, I would have pain during bowel movements or anal itching, sometimes to the point where I couldn't sleep (the stool isn't particularly hard; it just has a formed surface with cracks, slightly harder than my usual soft stools).
My questions are:
1.
Is rubber band ligation very painful? I experience pain during and after bowel movements, and the pain feels like cutting.
Isn't this type of pain typically associated with anal fissures?
2.
After each anal examination (not for ligation, just for follow-up on anal itching), there is always some bleeding from a specific area, which seems to occur because the examination causes the wound to reopen and bleed again.

3.
When I slightly pull the anal area outward, I can see a narrow wound.
Is this an anal fissure, or is it the wound from the internal hemorrhoid ligation? How can I differentiate between the two types of wounds?
4.
After ligation, I constantly feel the urge to have a bowel movement, but the stools are very small, and I can't seem to push them out, leading to a feeling of incomplete evacuation.
Some of the stool is covered with dark blood (some is bright red).
Is it normal to see dark blood?
I have undergone ligation five times already without any resolution.
I do not have constipation, I don't stay up late, and I take warm sitz baths.
Is there anything else I should be aware of?

Grace, 30~39 year old female. Ask Date: 2015/07/17

Dr. Cai Xingzhi reply Surgery

1.
Tissue necrosis and shedding after ligation may cause localized itching, which is normal; please take medication as prescribed by your physician.

2.
Anoscopy can easily cause bleeding due to the underlying condition (such as hemorrhoids), making bleeding more likely.

3.
Anal fissure wounds may present recurrent symptoms and are prone to scabbing.

4.
It is normal to notice a small amount of fresh blood at the anal opening a few days after ligation.

Reply Date: 2015/07/17

More Info

Hemorrhoids and anal fissures are two common conditions that can cause significant discomfort and pain during bowel movements. Understanding the differences between these two conditions, their symptoms, and treatment options is crucial for effective management.

Understanding Hemorrhoids
Hemorrhoids are swollen veins in the lower rectum and anus, similar to varicose veins. They can be classified into two types: internal and external. Internal hemorrhoids are located inside the rectum and are usually painless, although they can cause bleeding during bowel movements. External hemorrhoids, on the other hand, are located under the skin around the anus and can be painful, especially when a blood clot forms.

Symptoms of hemorrhoids may include:
- Painless bleeding during bowel movements
- Itching or irritation in the anal region
- Pain or discomfort, especially with external hemorrhoids
- A lump near the anus, which may be sensitive or painful

Understanding Anal Fissures
Anal fissures are small tears in the lining of the anus, often caused by passing hard stools, prolonged diarrhea, or anal intercourse. They can be extremely painful, especially during and after bowel movements. The pain is often described as a sharp, burning sensation, which can lead to a fear of bowel movements, creating a cycle of constipation and worsening pain.

Symptoms of anal fissures may include:
- Severe pain during and after bowel movements
- Bright red blood on the stool or toilet paper
- A visible tear or crack in the skin around the anus
- Spasms of the anal sphincter

Pain and Treatment Insights
1. Pain from Rubber Band Ligation: Rubber band ligation is a common treatment for hemorrhoids, where a rubber band is placed around the base of the hemorrhoid to cut off its blood supply. While this procedure is generally effective, some patients may experience pain during and after the procedure. The pain you are experiencing during bowel movements could be due to residual irritation from the ligation or the presence of an anal fissure, especially if the pain is sharp and resembles the pain of a fissure.

2. Bleeding After Anoscopy: If you notice bleeding after an anoscopy, it could indicate that the procedure has aggravated an existing fissure or caused irritation to the hemorrhoids. It’s essential to communicate this with your healthcare provider, as they may need to adjust your treatment plan.

3. Identifying Wounds: The presence of a long, thin wound may suggest an anal fissure, especially if it is painful and associated with sharp pain during bowel movements. In contrast, the wounds from hemorrhoid ligation may appear as a more localized area of irritation or swelling. A healthcare professional can provide a definitive diagnosis through a physical examination.

4. Bowel Movement Changes: The feeling of incomplete evacuation and the presence of blood on the stool can be concerning. While some blood is common with hemorrhoids, especially after ligation, the presence of dark blood may indicate a more significant issue. It’s crucial to monitor these symptoms and report them to your doctor. Persistent pain, changes in bowel habits, and blood in the stool warrant further investigation to rule out other conditions.

Additional Recommendations
- Dietary Adjustments: Ensure you are consuming a high-fiber diet to soften stools and reduce straining during bowel movements. Adequate hydration is also essential.

- Sitz Baths: Regular sitz baths can help soothe the anal area and promote healing.

- Topical Treatments: Over-the-counter creams or ointments may provide temporary relief from pain and itching.

- Follow-Up Care: Since you have undergone rubber band ligation multiple times without resolution, it may be beneficial to consult a colorectal specialist for further evaluation. They may recommend additional treatments, such as topical nitroglycerin, calcium channel blockers, or even surgical options if conservative measures fail.

In conclusion, both hemorrhoids and anal fissures can lead to significant discomfort, and distinguishing between the two is essential for effective treatment. If symptoms persist or worsen, seeking further medical evaluation is crucial to ensure appropriate management and relief from pain.

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