Anal Fissures: Medical (Non-Surgical) Treatment Regimen

While this is not specifically a WLS-related issue, anal fissures can be exacerbated by WLS-related issues (constipation, diarrhea) and can devastate your quality of life.

I posted a reference yesterday on another site to my having had problems with fissures in the past, and that I had worked out (tailoring a treatment regimen from recommendations on the internet, in consultation with my colorectal surgeon) a medical (as opposed to surgical) treatment for anal fissures.  Someone asked me about what it is, and since I wrote it all up this morning as a PM, I thought I would post the information as well.  So here you go:

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This is a MEDICAL (rather than surgical) course of treatment that works!

I should preface this with the fact that when my fissure was FINALLY properly diagnosed in 1995 (after THREE YEARS of incorrect and humiliating and painful treatments), the treatment was surgery, a sphincterotomy -- which is slicing the anal sphincter to stop the spasms and allow the fissure to heal (I think they also cut the scar and granulomatous tissue of the fissure to provide clean surfaces to heal together as well). That was the WORST surgery I have ever had, and the most painful -- and it was OUTPATIENT. I will freely admit that it DID cure the fissure, and I was pain-free for 10 years after the excruciating recovery period -- I needed demerol pills for several days after that surgery, it was that bad.

When I got my second fissure in 2006, I obviously was more educated and aware about them. Before I even went to see the colorectal surgeon, I did some intensive internet research, and went to the surgeon with a MEDICAL course of treatment I had found (well, modified from my research). This was particularly important to me because I had learned that doing a second sphincterotomy is a BAD idea -- you greatly increase the chances of fecal incontinence, and as a DSer, I occasionally need to exercise good sphincter control if I eat something that gives me gas or loose stools! I got him to agree to try my plan, and when it worked as well as it did, he said he was going to modify how he treated other patients!

This is what I did, which healed the fissure in 10 days:

Nitroglycerine paste: I believe this was a 5% formulation that had to be made up by a compounding pharmacist. Use a pea-sized dollop, applied directly to the fissure. Nitroglycerine is a muscle relaxant that calms down the spasms of the sphincter, which helps the fissure heal (rather than doing it surgically by sphincterotomy). It also is absorbed through the mucous membranes, so the first couple of times you use it, you should be at home in case it gives you a headache or makes you feel light-headed (as you probably realize, nitroglycerine is a heart medication). Use twice a day, AFTER you go poop.

Nifedipine pills: This is a heart medication that is also a muscle relaxant. I believe the dosage was 10 mg, taken twice a day orally -- as I recall, we opted against the time-release version due to the malabsorption. This supplements what the nitroglycerine does topically. Again, if you don't have high blood pressure, this treatment can make you feel a little lightheaded, but it should go away after a day or so as your body adjusts, and compared to the pain of the fissure, it is an acceptable side effect (to me). It can also be used as a topical treatment, which is what I first suggested to the surgeon, but he thought there was already too much medication being applied topically, which might prevent all of them from working well, so we opted for parenteral administration of this one, and it worked.

Lidocaine gel: I recall this was a STRONG prescription, 5%? Or, you can buy it over the counter at a sex toys store or online as Anal-Eaze (yes, used for what you are thinking ). You want to apply this gel BEFORE a poop to numb the pain, and then afterwards as well (after you apply the nitroglycerine paste). Again, this medication is absorbed through the mucous membranes, and should be used sparingly, because it can affect your heart rate.

Sitz baths: Or some equivalent, at least twice a day. I used a hand-held shower massage to get warm water directly to the area in the AM, and hot tub at night. You want to increase the blood flow to the fissure and thereby promote healing. Plus it makes it feel better.

In addition, you want to be particularly careful to not get constipated, to not strain while pooping (follow the mantra to just "let **** happen"), and to not pull your butt cheeks apart too far on the toilet -- a habit some of us get into to avoid the loose skin on the butt getting in the way, and also because it "feels" like that helps get the poop out, but which puts tension on the skin of the sphincter and can tear the healing tissue.

When I returned for a checkup after 10 days of this treatment regimen, my surgeon was amazed at the fact that the fissure was almost completely healed. And, I should note, it hasn't returned (knocking on several wooden objects).
 

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Please feel free to share this (assuming you are already "sharing" the perhaps TMI fact of having a fissure with someone in the first place).

Diana

Diana,

Thank you for posting this, this treatment saved me several times. Unlike the common "myth" that DSers have chronic diarrhea, I've had several bouts of constipation (rather hard poos) resulting from iron suppliments and once from trying an internal oder neutralizer called nullo. This last time (currently) it was a result of the iron and narcotic pain meds. Other wise things are very normal ...once a day in the morning.

I would like to add that if you are suffering from Dhr or constipation that you should treat it before it becomes an issue. It is much easier to prevent a fissure then to treat one (and much less painful...sh*tting glass is not fun). Stool softeners, extra fat, mild laxitives, and lots of veggies for constipation, and extra fiber for Dhr (plus it's important to coat your but with some type of ointment (think desitin) to protect the delicate tissue.

Also using baby wipes (the kind without alcohol) helps during clean up...instead of toilet paper, and I hate the witch hazel pads, they burn..and I never found them to help. Jumping into the shower after your final morning poo is also very helpful.....the warm water helps things relax, even better then medications.

As a "treatment" botox injections into the area has also been shown to be mildly sucessful. I guess as a last step before surgery. The only thing is that most insurance companies won't cover the drug and it costs about 300 dollars....but hey out patient surgery copays can be that much.

Last thing is DO NOT WAIT. If the pain starts, go see a doctor right away, it can go from bad to worse and then to "i'm going to pass out if I take a crap" very quickly.

Scott

PS newbies BOOK MARK this page, you may not need it now, but if you ever do, you'll want to be able to find it...TRUST ME!!!

Scott

Maybe I'm totally dense, but what are anal fissures?
Is it just a torn anus??

I just went to Wikipedia to find something to copy, and found not only the description of the condition, but very similar suggestions on how to treat it:
http://en.wikipedia.org/wiki/Anal_fissure

yes it's a tear in the tissue...and it is PAINFUL!!!! OMG think about your ass throbbing to the point of tears without relief....then having to have a BM and feeling like glass is coming out....and the worst part of it is that pain meds really don't help...it sucks big time!!! Best to avoid them completely if you can.

Scott

I have heard that anal fissures are most painful and least talked about things so thanks Diana  for providing us with such great advice. Great idea Scott, I am bookmarking for sure.

Bev

I so appreciate you sharing this information. I've not had a problem before, but you never know!! Also, I am guilty of the moving the butt checks out of the way maneuver you mention and you've convinced me to stop! I am bookmarking this page in case I may need it sometime down the road.

Thanks,

Jillian

i'm so glad i read this. i was born with a hemmeroid, and have had constipation issues my enitre life, which have worsened recently, and just started on amitizin (i think it's spelled) to make me GO...and this morning was hard on me, and i felt a real sharp pain in a not too normal spot for pain ...and from the talk of the pain level and of course location, i'd say it's the beginnings of a fissure. i was sorta straining, which i don't normally do and BOY did it hurt.
anyway, i'm going to be more careful and start treating it as if it is one, just in case. Thanks!

With all the posts about constipation the last few days, I figured I'd bump this up...someone is bound (no pun intended) to need it.

Scott