Anal Fissures: Treatment Options and Healing Insights

Anal fissure issues?

Hello, Dr.
Ke! Last year, I had a severe anal fissure on the right side, which I later treated at a general clinic.
The doctor removed the fibrotic tissue, and it healed over about a month and a half.
This year, the fissure occurred on the left side.
When I visited a surgical clinic, I initially thought it was just an external fissure, so I frequently took sitz baths.
The doctor prescribed me general antibiotics and suppositories.
After about two weeks, the external fissure healed, but when I went to the hospital, the doctor mentioned there was still a small fissure inside the anal canal and prescribed me suppositories and hemorrhoid ointment.
However, the doctor said since I had already used suppositories, I didn't need to use them for many days; sitz baths would suffice, and I could use medication if I felt uncomfortable.
After picking up my medication, I asked the hospital pharmacist if applying the ointment externally would allow it to be absorbed internally.
The pharmacist said it would.
So, I used the suppositories for a few days and have temporarily stopped using them (it's been almost two weeks now).
Later, when I had a cold and visited the same surgical clinic, I asked the doctor again if applying the ointment externally could be absorbed internally.
The doctor said it was not possible, and the pharmacist also confirmed that it couldn't.
However, the doctor prescribed me general antibiotics and suggested that I squeeze a bit of the ointment onto my finger and insert it near the anal opening.
He mentioned that if the tube for the hemorrhoid ointment wasn't positioned correctly, it might touch the internal wound again.

Now, a month has passed, and during my follow-up appointment last week, the doctor said the internal wound had healed about halfway, and I should continue with the current treatment.
I do not experience bleeding when I have soft stools, and there is no pain (only slight pain with hard stools, but no bleeding).
However, the frequency of my bowel movements varies (at least three times a day, similar to my previous habits, but now I rely on softening my stools).
I generally do not feel discomfort, so do I still need to use the suppositories? Is it true that applying the ointment externally cannot be absorbed internally?
I suddenly recalled that the surgical clinic doctor mentioned that since I had treatment on the right side, there is some scar tissue, and now that the left side is healing, it might be pulled by the scar tissue on the right side, which means "it might only heal to a certain extent," but he also said "it will still heal; we just don't know how long it will take."
So, regardless of whether I use hemorrhoid medication or general antibiotics, after how long will the internal scar tissue be the same? What should I do then? Will I need surgery? Will long-term use of medication (mostly antibiotics, which are the mildest type) lead to antibiotic resistance? I know this is a lot of information, but I wanted to clarify my questions.
I appreciate your insights, Dr.
Ke.
Thank you!

ken, 30~39 year old female. Ask Date: 2015/11/23

Dr. Ke Fangxu reply Surgery

First of all, please do not misuse antibiotics.
Using antibiotics without signs of infection is harmful and unhelpful.
Since you currently have no bleeding or pain, what is the purpose of treatment? The goal of treating anal conditions is to relieve uncomfortable symptoms, but it seems that you do not have any issues that require treatment at this time.
Please do not fixate on scars or wounds; as long as you have smooth bowel movements without discomfort, there is no need for long-term medication.

Reply Date: 2015/11/23

More Info

Anal fissures are small tears in the lining of the anus, often causing significant discomfort and pain during bowel movements. Your experience with anal fissures, particularly the recurrence and the treatments you've undergone, is not uncommon. Let's break down your situation and explore the treatment options and healing insights.

Understanding Anal Fissures
Anal fissures can occur due to various reasons, including passing hard stools, prolonged diarrhea, or trauma to the anal area. They can be acute (recently developed) or chronic (lasting more than six weeks). Chronic fissures often develop scar tissue, which can complicate healing.

Treatment Options
1. Conservative Management: This typically includes dietary modifications to ensure soft stools, such as increasing fiber intake and hydration. Stool softeners may also be recommended to ease bowel movements.

2. Sitz Baths: Regular sitz baths can help soothe the area, promote blood flow, and aid in healing. It seems you have been doing this, which is beneficial.

3. Topical Treatments: The use of topical anesthetics, steroid creams, or nitroglycerin ointment can help relieve pain and promote healing. It’s important to follow your doctor’s advice regarding the duration of use for these medications.

4. Botulinum Toxin Injections: In some cases, botulinum toxin can be injected into the anal sphincter to relax the muscle, reducing pain and allowing the fissure to heal.

5. Surgery: If conservative treatments fail, surgical options such as lateral internal sphincterotomy may be considered. This procedure involves cutting a small portion of the anal sphincter muscle to relieve tension and promote healing.

Healing Insights
- Scar Tissue: As your doctor mentioned, the presence of scar tissue from previous fissures can affect healing. Scar tissue can be less flexible, which may lead to a situation where the new fissure struggles to heal completely. This is a common issue in patients with a history of anal fissures.

- Monitoring Symptoms: Since you are not experiencing bleeding or significant pain with soft stools, this is a positive sign. However, if you notice any changes, such as increased pain or bleeding, it’s essential to consult your healthcare provider.

- Duration of Treatment: The duration for which you should continue using topical treatments can vary. Generally, if you see improvement and the fissure is healing, you may not need to continue indefinitely. However, if symptoms persist or worsen, further evaluation may be necessary.

- Antibiotic Use: Long-term use of antibiotics can lead to antibiotic resistance, which is a valid concern. It’s crucial to use them only as prescribed and to discuss any ongoing need for antibiotics with your healthcare provider.

Conclusion
In summary, it sounds like you are on the right track with your treatment. Continuing with sitz baths, maintaining a high-fiber diet, and using topical treatments as needed are all good practices. If you find that your symptoms do not improve or if you have concerns about the healing process, it would be wise to follow up with your healthcare provider for further evaluation. They may consider additional treatments or even surgical options if necessary.

Remember, healing from anal fissures can take time, and patience is key. If you have any further questions or concerns, don’t hesitate to reach out to your healthcare provider for personalized advice.

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