Anal fissures are not exactly a topic for cocktail party conversation, and the reluctance to discuss them often leaves sufferers thinking they are the only ones affected.
In fact, this potentially painful, debilitating, anxiety-provoking condition is quite common. If a fissure doesn't heal on its own, it can usually be treated and recurrences prevented with conservative measures.
"Most people don't know they exist because nobody wants to talk about them," Emma Rushton of Nashville, said in an email that urged me to write about the treatment and prevention of these tiny tears in the anal opening. "Believe me, when I was struck down by mine, the last thing I wanted to do was tell people."
So like many others, she suffered in silence. "Every bowel movement was painful, and the agonizing after-spasms went on for hours," she wrote. "Even when I wasn't in actual pain, it was all I could think about. My work suffered; my life was on hold."
If you've ever noticed bright red blood on toilet tissue or in the bowl after a bowel movement, chances are it is a small tear in the rim of the anus. Such tears are commonly mistaken for hemorrhoids, which unlike fissures don't cause pain with bowel movements.
In an estimated 90 percent of cases, these tears heal on their own. When they don't, every subsequent bowel movement — especially if the stool is large, hard and dry — can reopen the wound and result in a chronic problem that persists for more than a month. The tear need not be very big to cause considerable discomfort.
As with a small cut on the pad of the thumb, every use hurts the injured area, and even worse, can aggravate the wound.
Any trauma to the anal canal can cause a fissure. In women, childbirth is a common cause. Other causes include the insertion of a foreign object, anal intercourse, a digital rectal exam and chronic constipation or diarrhea. Fissures often affect people with inflammatory bowel disease and Crohn's disease.
Chronic tension in the internal anal sphincter — the muscular ring that surrounds the anal canal — is often an underlying factor because it reduces blood flow to the region. This renders the anal lining more susceptible to tearing and makes it harder for fissures to heal.
If you have a fissure, the sharp, stinging or burning pain that occurs with a bowel movement can be brief or long-lasting. And, as Ms. Rushton experienced, debilitating spasms can persist for hours.
The resulting agony can prompt people to try to postpone a bowel movement, which only complicates matters by making the stool harder and more difficult to pass.
Anyone experiencing symptoms should consult a doctor who can determine the cause. It is unwise to assume rectal bleeding, however slight, is innocuous. The doctor can examine the anus and the anal canal in the office with the unaided eye or by using a small instrument called an anoscope.
If a more serious problem must be ruled out, a sigmoidoscopy or colonoscopy may be recommended.
When an anal fissure fails to heal quickly on its own and causes repeated pain, conservative treatments can speed healing. Most often, the doctor will recommend taking a sitz bath two or three times a day: sitting in plain warm water for about 20 minutes at a time. Sitting on a warm heating pad or a hot water bottle is also helpful because heat increases blood flow to the anus and promotes healing.
Cleanse the area with water only; using soap can dry out the lining of the anal canal. Moisturize the anal sphincter with a neutral lubricant like coconut oil, applied several times a day and at bedtime. Pain can be relieved with an oral painkiller.
Unless diarrhea is a cause, measures to soften the stool and promote regular bowel movements are most helpful. These include taking an oral stool softener like docusate sodium (Colace) and a daily fiber supplement like Metamucil, Konsyl, Citrucel or Fibercon; eating high-fiber foods like dried and fresh fruits, vegetables, bran and other whole grains; and drinking two or more quarts of water a day.
Also avoid foods that tend to be constipating: cheese and other dairy products, bananas, white rice, chocolate, large amounts of red meat, fried foods and chips. And replace low-fiber white breads and cereals in your diet with high-fiber whole-grain versions.
Caffeinated beverages like coffee and tea can be a double-edged sword. Although they may ordinarily stimulate a bowel movement, they can be constipating if you are dehydrated.
Also helpful is regular physical exercise, which promotes bowel regularity and increases anal blood flow. Moderate activity like walking at least 30 minutes a day, most days of the week, can help keep your digestive system functioning normally and foster overall health.
It is always important to avoid straining during bowel movements, which can reopen an anal tear that has healed or cause a new tear.
Persistent symptoms of an anal fissure usually require medical treatments. Nitroglycerin applied externally, which finally healed Ms. Rushton's fissure, can foster blood flow and relax the anal sphincter, as can some blood pressure medications. A steroid cream can reduce discomfort. An injection of Botox can be used to temporarily paralyze the anal sphincter and relieve spasms.
Advice from Ms. Rushton, who has become a reluctant lay expert on the condition: "If the first things you try don't work, keep trying."
Only when such conservative measures have failed to cure an anal fissure is surgery likely to be necessary. Surgery typically involves cutting a small part of the anal sphincter muscle to prevent spasms. There is a small risk that the operation will result in fecal incontinence.
Needless to say, preventing anal fissures is more desirable than having to treat them.
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