Anal Fissures and ways to treat 'em

Well, in Constipation its causes its side effects and treatment procedures we discussed about constipation. I discussed about anal fissure too. But I believe the problem is sooo big and common that it deserves its own main thread. And hence I am writing a new topic. And I will definitely add new content and some rectifications based upon my experience. So, it's not going to be the typical copy paste article. 

What's Anal Fissure

Well, we have sphincters all over our GI tract, urinary tract etc. Sphincter is a round muscle, which acts as a one way valve. When we talk about anus, it has two sphincters, Sympathetic sphincter muscle and Parasympathetic sphincter muscle ones respectively. Inner sphincter is the Sympathetic one and outer sphincter is the Parasympathetic one. So, what do they do? Sympathetic sphincter muscle allows us to control the urge to poop. Anal Fissure occurs when a tear forms on Sympathetic Sphincter Muscle. Our GI tract doesn't have any pain receptors other than on its both open ends, e.g. mouth and rectum/anus. And the fissure is located on lower third of the anal canal(below Pectinate Line), which contains the two Sphincter Muscles. That's why we feel the pain. Otherwise it would be rather painless. And that's why intestinal bleeding can get unnoticed. We are especially at risks as most of us don't undergo colonoscopy at least once after 40. And colonoscopy is seldomly advised by our doctor as most of us visit a normal Medicine Specialist. And colonoscopy can be expensive as well. As a lot of us don't have insurance coverage, we just silently watch and observe until it gets severe. 

Causes of Anal Fissure

1. Number one cause is Constipation. And constipation can be there for a ton of reasons e.g. Junk Food, Food Allergy, Opioid based meds etc.
2. Some sort of trauma, Foreign Objects, Pregnancy and Childbirth, Straining etc 
3. Some pre-existing medical condition like tight sphincters.
4. Irritable bowel syndrome (IBS) and Inflammatory bowel disease (IBD) (Both deserve their own separate threads)
5. Diseases like Syphilis and Herpes.
6. Sometimes medical tests like Colonoscopy itself can cause the tear.

How to identify the Anal Fissure? And who can identify? Who is recommended?

If you feel sharp pain during defecation process, see blood smeared stool, then maybe you have anal fissure. A doctor can and will identify the problem. Pain while defecation and blood smeared stool can be misdiagnosed with other diseases like fistula and piles. A Proctologist is the one, who is recommended. They might just either listen to your problem or do a physical examination. They usually do this digital examination. They might suggest for an Anoscopy. In severe cases  Colonoscopy might be recommended. Sometimes the symptoms last for 2-3 hrs or more because of muscle spasm. One might find difficulties in performing regular tasks e.g. walking, squatting, sitting on chair. Please, don't self diagnose your problem as most of us are not qualified doctors. 

Treatment Procedure

Non-surgical treatments

In Non Surgical methods, home remedies for Constipation will be prescribed. We have discussed about them in detail the Constipation thread itself. And for Pain and Inflammation Management NSAIDs e.g. Ketoral-DT can be prescribed. Paracetamol is also seen prescribed. Please be ware if the physician prescribes you Ultracet. It has opioid Tramadol. It will definitely, definitely gonna cause constipation if you are already suffering from the problem. Just notify the doctor but s/he gonna chase you away most probably. So, just find another one. You might be prescribed a Liquid Paraffin based stool softener along with Milk of Magnesia e.g Cremaffin. In extreme cases you might be prescribed a contact stimulant laxative e.g. Sodium Picosulfate e.g. Cremaffin Plus, Mom Plus etc. Demerit of stimulant laxative is it can not be used long term. Both Cremaffin and Cremaffin Plus can't be use for a long duration and Cremaffin is non habit forming one that's why it can be availed OTC. But Cremaffin Plus is a habit forming laxative. So, if you are being prescribed for a long duration, share your concern with the physician. If the physician is adamant on giving it to you then share your concern with another physician. Please ask for the exact dosage as they want you to have semi solid stool. You might be prescribed Prucalopride. On the ointment part we have a lot of OTC ointments e.g. Pilex Forte, Pilon. But the doctors seldomly prescribe those OTC ointments. They will rather prescribe a combination of a local anesthetic Lignocaine gel and other protective layer forming agents e.g. Sucralfate. Ex: Sucral Ano. Application method is to either take a pea sized ointment on your rubber gloves covered hands and apply inside the anus or use the applicator tip. You might be prescribed Lignocaine gel, e.g. Lox 2% / Lox 5%. These are usually used while inserting the catheter. Doctors advise to apply it 20 mins before going to toilet. Lox 2% / Lox 5% will numb the area. You will not face any pain. Please check the Adverse Effects of Lignocaine Gel. And share your concerns with your prescribing physician if you find anything similar to those problems. 

If Anal Fissure heals within 4-5 weeks then alright, otherwise it will go to chronic phase. And the usual reason is Constipation but another reason is muscle spasm. Anal Muscle Spasm i.e. Proctalgia does not allow the fissure to heal. So, to relax them they use radical methods 🐒🐒🐒. The ointments contain same active components which are used to treat hypertension. First ointment of choice is Nitroglycerin. It's a nitro vasodialater. Ex: Rectiv. Other drug of choice is Diltiazem. Ex: Cremagel .  Diltiazem vs Nitroglycerin. Next drug of choice is Nifedipine, ex Anobliss, Fisofine etc. Nifedipine vs Diltiazem and both of em are Calcium Channel Blockers. Nifedipine is kinda baap of all creams in order to treat rectal muscle spasms. 🙂🙂🙂 And these vasodialators and Calcium Channel Blockers come with a lot of warnings. If overdosed they can lower blood pressure. You might feel dizzy, nauseated. Talk to your Doc for proper guidance. I have seen those creams come with applicators. That's the problem. The problem is vasodialators and Calcium Channel Blockers don't act as a healing agent. Their purpose is to relax that stubborn Internal Anal Sphincter. So, direct application on the wound itself is unnecessary.

Just follow the video. And don't apply a ton of vasodialators and Calcium Channel Blockers creams. Tiny amount is enough. Share your concerns with your prescribing doc. 🙂

Surgical Treatment

They might give you quite some options. One option is Botox injections. It will paralyze the affected area and allow the healing process to be complete. As it's a quite painful option, I am including it under surgical treatment. Second option is Anal Sphicterotomy. It can be done by a skilled surgeon most preferably by laser. Side effect of Anal Sphicterotomy is Fecal Incontinence. It is what it is. And most probably it will go away after a while.

Some Interesting Bummers One I/ Faces/ed During Healing Process

> Too much fiber intake can make you constipated. They keep on saying take fiber, take fiber supplements. But as always Ati Sarvatra Garhitam (Excess of anything is bad). Check this video.

Basically first part of stool will be very hard and thick. It will just act as a sand paper on the wound. Rest of the stool will be very soft. I have personally felt it. The doctor increased Cremaffin dosage. I had to number 2 twice. First part will be sooo painful. Muscles will spasm like crazy. After 10 mins, I will go again. Soft poop will make the situation very miserable. I was given Cremaffin Plus. I intentionally avoided the same as it is very addictive. 

> Some food will make the issue very worse. They say ripe banana as a source of fiber. Yes, it is true. But it made my case worse. Months after months passed. I gulped bananas day, afternoon and evening. Damn. Even that Anobliss thing did not work. I had that comet poop thing. 40ml of Cremaffin did not work. 

> Opioids will make things worse. Meds like Ultracet will make the similar issues. A good physician will never prescribe it to a constipated person. Stool did not come out. It remained stuck. It was super painful. I had to strain and reopened the fissure. I stopped em. I stopped em all. Anobliss works for me. And for pain management, it is better to bite the bullet and take it like a champ. If you can't sit lay down on your stomach. WFH saved me, honestly. Otherwise do this 

Just kidding. I listened to a bunch of metal songs like Custer, Walk, The Nameless etc before and after pooping. Man, those helped me a lot. You basically go like a warrior and come back injured. Stupid stuff.

> Flax seeds works. I roasted 'em and ate 'em. Apples worked wonders. 

> If you have IBS then consider this https://www.ibsdiets.org/fodmap-diet/fodmap-foo... list of foods. 

Go follow this Proctologist's channel Your Friendly Proctologist. He gives good info. Follow your physician. Don't forget to Google your meds. Know the composition. If doubt arises then go talk to that doctor. You will alienate some doctors as nobody wants to be taught to how to do one's job. But its your bum in the line, quite literally. And before opting for surgery, ask for for the complications, cost, ask a second opinion. My physician, a medicine specialist, who is a very nice person, charges me 500 bucks per visit. But he also gives free treatments to the needy person. If you say you don't have any money, he will treat you. If you say that please take fee every alternate visits then also he will agree. And during these visits we have developed this mutual respect for each other. He suggested me to go to a surgeon/proctologist. Surgeon gave me Ultracet. I suffered. I googled and I saw it has a narcotic component. You know, I have this habit of digging around things. It was late but I managed to save myself from further problems. I asked the doc. He confirmed the same. My earlier physician also recommended me to go to a homeopathy doc. That's strange. Keep your options open. Isobgol/Psyllium is reportedly a good constipation treatment. But as with other laxatives, please don't over do it.

 Please don't self treat yourself. I don't have any meds degree.

Feel free to share your experience.