The rectum is the last foot of your colon, and it naturally stretches to hold stool. Hemorrhoidal piles are natural clusters of blood vessels that help the rectum and anal canal stretch to hold stool and allow bowel movements to eliminate feces. Sometimes the anus can tear, resulting in an anal fissure. Such a tear is very painful. The pain causes the sphincter to spasm. The cramping makes defecation more difficult, keeping the tear open. The cramped tissue has poor blood supply & keeps the anal fissure from healing.
The key symptom of an anal fissure is pain. Patients complain of severe sharp stabbing pain during defecation. It is often confused for hemorrhoids, but hemorrhoidal pain is usually irritating where patients feel burning after the bowel movement. Fissures take weeks to heal.
Avoiding the most frequent causes listed below will prevent most cases of anal fissures:
- Hard stools
- Constant sitting
- Straining with bowel movements
- Sitting on the toilet for a long time
- Severe coughing episodes
- Pregnancy / Childbirth
- Heavy Lifting
Sometimes avoiding the above triggers is difficult: How can you avoid sitting all day if you have a seated job? Also, we try to avoid coughing and diarrhea, but sometimes it’s beyond your control. Still, there are some practical hints to help:
- Keep the anal and genital area clean. Moistened tissues such as flushable wet wipes are less irritating than toilet paper. Using irrigating showers or bottle irrigation washing gently cleans this sensitive area. Avoid dry toilet paper when cleaning after bowel movements. .
- Keep the anal and genital area dry. Lightly pat the rectal area dry. Avoid rubbing. Talcum or baby powders can help
- Get your stools soft. This is the most important way to prevent irritated hemorrhoids. Hard stools are like sandpaper to the anorectal canal and will cause more problems. The goal: One soft bowel movement a day! BMs from every other day to 3 times a day is a tolerable range
- Treat coughing, diarrhea and constipation early since irritated hemorrhoids may soon follow.
- If your main job activity is seated, always stand or walk during your breaks. Make it a point to stand and walk at least 5 minutes every hour and try to shift frequently in your chair to avoid direct rectal pressure.
- Always exhale as you strain or lift. Don’t hold your breath.
- Do not delay or try to prevent a bowel movement when the urge is present.
- Exercise regularly (walking or jogging 60 minutes a day) to stimulate the bowels to move.
- No reading or other activity while on the toilet. If bowel movements take longer than 5 minutes, you are too constipated.
Drink plenty of liquids (1.5 to 2 quarts of water and other fluids a day unless fluid restricted for another medical condition). Liquids that contain caffeine (coffee a, tea, soft drinks) can be dehydrating and should be avoided until constipation is controlled. Consider minimizing milk, as dairy products may be constipating.
Eat plenty of fiber (30g a day ideal, more if needed). Fiber is the undigested part of plant food that passes into the colon, acting as “natures broom” to encourage bowel motility and movement. Fiber can absorb and hold large amounts of water. This results in a larger, bulkier stool, which is soft and easier to pass.
Eating foods high in fiber – 12 servings – such as:
- Vegetables: Root (potatoes, carrots, turnips), Leafy green (lettuce, salad greens, celery, spinach), High residue (cabbage, broccoli, etc.)
- Fruit: Fresh, Dried (prunes, apricots, cherries), Stewed (applesauce)
- Whole grain breads, pasta, whole wheat
- Bran cereals, muffins, etc.
Consider adding supplemental bulking fiber which retains large volumes of water:
- Psyllium ground seeds –available as Metamucil, Konsyl, Effersyllium, Per Diem Fiber, or the less expensive generic forms.
- Citrucel (methylcellulose wood fiber)
- FiberCon (Polycarbophil)
- Polyethylene Glycol – and “artificial” fiber commonly called Miralax or Glycolax. It is helpful for people with gassy or bloated feelings with regular fiber
- Flax Seed – a less gassy natural fiber
Laxatives can be useful for a short period if constipation is severe
- Osmotics (Milk of Magnesia, Fleets Phospho-Soda, Magnesium Citrate)
- Stimulants (Senokot, Castor Oil, Dulcolax, Ex-Lax)
- Laxatives are not a good long-term solution as it can stress the bowels and cause too much mineral loss and dehydration. Avoid taking laxatives for more than 7 days in a row.
Switch to liquids and simpler foods for a few days to avoid stressing your intestines further.
Avoid dairy products (especially milk & ice cream) for a short time. The intestines often can lose the ability to digest lactose when stressed.
Avoid foods that cause gassiness or bloating. Typical foods include beans and other legumes, cabbage, broccoli, and dairy foods. Every person has some sensitivity to other foods, so listen to your body and avoid those foods that trigger problems for you.
Adding fiber (Citrucel, Metamucil, FiberCon, Flax seed, Miralax) gradually can help thicken stools by absorbing excess fluid and retrain the intestines to act more normally. Slowly increase the dose over a few weeks. Too much fiber too soon can backfire and cause cramping & bloating.
Probiotics (such as active yogurt, Align, etc) may help repopulate the intestines and colon with normal bacteria and calm down a sensitive digestive tract. Most studies show it to be of mild help, though, and such products can be costly.
- Bismuth subsalicylate (ex. Kayopectate, Pepto Bismol) every 30 minutes for up to 6 doses can help control diarrhea. Avoid if pregnant.
- Loperamide (Imodium) can slow down diarrhea. Start with two tablets (4mg total) first and then try one tablet every 6 hours. Avoid if you are having fevers or severe pain. If you are not better or start feeling worse, stop all medicines and call your doctor for advice
Call your doctor if you are getting worse or not better. Sometimes further testing (cultures, endoscopy, X-ray studies, bloodwork, etc) may be needed to help diagnose and treat the cause of the diarrhea.
Treatment of Anal Fissure Flare
If these preventive measures fail, you must take action right away! Fissures can be confused with another anorectal problems such as hemorrhoids or perirectal abscesses.
Most anal fissure pain takes several weeks to calm down. These suggestions can help:
Warm soaks. This helps more than any topical medication. Use up to 8 times a day. Usually sitz baths or sitting in a warm bathtub helps. Sitting on moist warm towels is helpful. Switching to ice packs/cool compresses can be helpful
Normalize your bowels. Extremes of diarrhea or constipation will make hemorrhoids worse. One soft bowel movement a day is the goal. Fiber can help get your bowels regular
Wet wipes instead of toilet paper
Pain control with a NSAID such as ibuprofen (Advil) or naproxen (Aleve) or acetaminophen (Tylenol). Narcotics are constipating and should be minimized if possible
Topical creams contain steroids (hydrocortisone) or local anesthetic (xylocaine) can help make pain and itching more tolerable.
If you are still having pain, you could benefit by an evaluation by a surgeon. The surgeon will obtain a history and examine you. If an anal fissure is confirmed, treatment options are available beyond the above recommendations:
- Muscle relaxing creams (Diltiazem, Nifedipine, Nitroglycerine) help the sphincter muscles relax and allow the fissure wound to heal. Most studies show that 75% of fissures will heal with the use of a muscle relaxing cream by 3-6 weeks.
- Lateral internal sphincterotomy. This involves an operation where part of the anal sphincter muscle is cut to allow the sphincter to relax & no longer spasm. This allows the anal fissure to heal.
Treatment options do have risks for potential complications. Your surgeon can help offer recommendations once you are evaluated.