Two and a half years with a chronic fissure: a summary

Hi

As I am now healed of my chronic fissure after 2.5 years, I thought it may be helpful for people now (or in the future) if I just summarise the main things and any learnings from it.

1) 2004 - severe anal pain and bleeding with and after BM over several months. Medical treatment prescribed by GP not effective plus headaches. Referred in agony to a good CRS – sent straight to hospital with a chronic fissure and botoxed the same day (December 2004). Took at least 10 weeks to heal.
2) 2007 – over a period of at least 9 months intermittent bleeding and pain with BM. Referred to the above CRS who did colonoscopy and haemorrhoid banding. Took several months for pain to ease after banding.
3) Late 2007 – early 2008 some weeks after banding, a bad case of constipation followed by bleeding (I will never force it out again!). Self-diagnosed with fissure. Based on advice from a friend applied Amoils (organic oils available over the internet) internally on a cotton bud for about 5 months. Also saw GP who advised Lactulose as Metamucil seemed ineffective.
4) August 2008 – referred again to the above CRS who diagnosed a chronic fissure and did the first LIS. After several weeks of pain developed a haematoma. Continued to have fissure pain after surgery healed.
5) February 2009 – because first LIS (which was done conservatively) clearly unsuccessful, the CRS did a second one. After about 3 weeks some minor incontinence for a couple of weeks – air and small solids (just 2x). Definitely felt this surgery resulted in a more relaxed sphincter muscle.
6) Around May 2009. As second LIS unsuccessful to that time, started applying 0.2% nifedipine. No side effects and seemed to make sphincter muscle more relaxed. Also went from Lactulose to Miralax - much better! But still almost constant pain throughout the day. To this point I had needed to take 55 days sick leave since problem first arose because of the pain.
7) The CRS said my fissure was the worst he had seen and he could not help me any further as thought too dangerous to do further surgery - so referred me to one of the best CRSs in the country (Australia). This CRS spent several months carrying out tests before deciding the next step. He saw three options initially - another LIS, anal flap surgery or nothing. Also increased nifedipine to 0.5%. He (as did the previous CRS) ruled out the common reasons why LIS didn't work eg Crohns. Two important tests he performed were an ultrasound (to see what impact the previous 2x LIS had on the sphincter muscle - no damage showed up) and manometry (to see if the sphincter muscle was above average tightness and hence preventing good blood and oxygen circulation for healing - results along the length of the canal showed well above average pressures).
So based on this we decided there was only a small risk of incontinence with a third LIS and so mid-December 2009 went under the knife again.
9) Just a comment on the surgeries - I never needed pain killers after any of them (except a panadol one night to help me sleep) and the first BM on about the second or third day with each, while it hurt, was nowhere near as painful as the fissure in its glory days. Surgery is not as bad as we might fear, especially if done by a good CRS.
10) Saw CRS end-January 2010 - said healed.
11) January to April 2010 - ongoing pain which just felt like fissure pain so went and saw CRS again in April - did an anuscope and said fissure definitely healed as were the cuts (besides the LIS he removed two skin tags associated with the fissure) and there was no significant scar tissue. But said I had some minor leakage (not enough to soil underwear or be noticeable to me) and through the day this was irritating/burning the skin. Said to get BMs harder and better formed - this included changing my diet (I had been living on soup and fruit with cereals for breakfast and sandwich for lunch) to decrease the very high levels of fibre I was having, and also cutting out miralax completely and applying zinc oxide 3x a day. Did these changes (diet and miralax gradually) and pain has virtually gone! Yesterday was totally pain free - first time in 2.5 years! Since surgery in December my BMs (1x per day) just takes 10 seconds regardless of size. Am now eating whatever I want except for avoiding junk feed, cheese and chillies / hot curries.

Some of my learnings (but noting we are each unique):
1) Never force a BM!!!!!!
2) Make sure a good diet with fibre and plenty of water.
3) Metamucil often made things worse. Miralax and benefibre complement each other really well and can modify to control the BM.
4) While healing keep BMs soft but not too bulked up by going to excess with fibre - only made it worse.
5) Great to have someone close to share your experiences (including how you are feeling) with. If that person is not around than this group is very good!
6) Only go to a good CRS (if one is available locally) - don't risk one you do not feel comfortable with or who is not extremely experienced with a good track record. I had to travel 150 km to see the second one - it was worth it.
7) Don't have a second or third LIS without an ultrasound and manometry as well as having had crohns etc ruled out. Some poeple will not be suitable for a subsequent LIS - eg they may have sphincter muscle damage from a previous event such as child birth and will be at very high risk of incontinence!
If your fissure is healed but you still have pain, this could be from the same problem I have had and you may need to work towards having better formed and harder (but not too hard) BMs.
9) Don't waste time and money on products advertised on the web - stick with those things for which there is an evidence base.
10) God's grace is sufficient no matter what our circumstances - if only we look to Him.

Thats all I can think of at the moment. I really feel for those that have had surgery and still not healed - the roller coaster ride is tough! Juney, I'm thinking particularly of you here - trust you experience major relief and healing in the future.

Charles

Giving ya a bump to the top for an excellent thread. It's great to hear that you got everything sorted out Charles, sounds like you had quite an adventure I wish I had access to this kind of information when I first got my fissure. Future fissure victims will appreciate that a kind soul like yourself shared it here

Hi NG thanks for your kind words. Trust you have a good road to healing over these next days following your LIS.

I thought I should add one thing to complement my point 9 above (learnings). For those who want to suss out the evidence base, and have access to online medical papers (eg through a university or work), I highly recommend reading one or more review papers on anal fissures. Some that you may find helpful include:

The management of anal fissure: ACPGBI position statement. [Review] [47 refs] Cross KL. Massey EJ. Fowler AL. Monson JR. ACPGBI. Colorectal Disease. 10 Suppl 3:1-7, 2008 Nov.

Hemorrhoids and fissure in ano. [Review] [131 refs] Chong PS. Bartolo DC. Gastroenterology Clinics of North America. 37(3):627-44, ix, 2008 Sep

Nonsurgical approaches for the treatment of anal fissures. [Review] [84 refs] Dhawan S. Chopra S. American Journal of Gastroenterology. 102(6):1312-21, 2007 Jun.

Non surgical therapy for anal fissure. [Review] [71 refs][Update of Cochrane Database Syst Rev. 2003;(4):CD003431; PMID: 14583976] Nelson R. Cochrane Database of Systematic Reviews. (4):CD003431, 2006.

Systematic review: the treatment of anal fissure. [Review] [98 refs] Steele SR. Madoff RD. Alimentary Pharmacology & Therapeutics. 24(2):247-57, 2006 Jul 15.

Operative procedures for fissure in ano. [Review] [33 refs][Update of Cochrane Database Syst Rev. 2002;(1):CD002199; PMID: 11869628] Nelson R. Cochrane Database of Systematic Reviews. (2):CD002199, 2005.

A systematic review of medical therapy for anal fissure. [Review] [37 refs] Nelson R. Diseases of the Colon & Rectum. 47(4):422-31, 2004 Apr.

Chronic anal fissure. [Review] [84 refs] Lindsey I. Jones OM. Cunningham C. Mortensen NJ. British Journal of Surgery. 91(3):270-9, 2004 Mar.

All the best
Charles

Sorry - one more paper that I have found helpful - for those wondering about the effect (short and long term) of LIS on the tightness of the anal sphincter muscle, this is a good paper with some interesting graphs:

Internal anal sphincter function following lateral internal sphincterotomy for anal fissure: a long-term manometric study. Ram E. Alper D. Stein GY. Bramnik Z. Dreznik Z. Annals of Surgery. 242(2):208-11, 2005 Aug.

Charles

THANKS SO MUCH for posting this !!! I am sure that many will find this helpful and encouraging !!!!!

hummm... i since my lis surgery i have been taking metamucil.... its hard to keep it consistent... its usually really mushy...

i guess i will try benefiber

Benefiber works well for me!

charles - i just signed on for the first time in awhile and was reading your post thinking how much it could apply to me and then i saw you mentioned me at the bottom. thank you for the advice!
i had a painfree 6 month stretch after botox (the best 6 months i've had in years!!) but the past couple weeks the pain has come back and i'm getting frustrated again. i think i might have some leakage (not enough to be noticeable) which causes the pain for several hours after BM. i'm trying to reduce my miralax dose but i'm really nervous after using it for so long. thank you for your post, all the advice, and the article links. even though i don't come on much anymore, i'm so thankful for the support of everyone here.

Hi

I'm new here but it is great to hear that you are better and also to hear your encouraging story. I think your middle name should be perseverance!

Juney - I am so happy to hear that you are doing so much better (KTW ) and I hope that you will find out one last trick of how to manipulate poop consistency and make your butt completely happy

That is just fantastic news !!!!!

Would you consider having a Botox again perhaps - since it helped so much ???

Wishing you complete and forever healing

fissy - i'm going back for more botox next week so my saga hasn't ended....but 6 months painfree was sooooo nice i almost felt like a normal human again!!! fingers crossed i get that same relief with another shot.

That is just wonderful, dear Juney Oh my KTW KTW KTW :luckyeyes: What a relief it is to hear all of that I was thinking about you so very often !!! Last time you posted you sounded still disheartened and down and I was very saddened by that ... It is such a shame that you had to suffer for sooooooo long just because they obviously did not do correct LIS TWO TIMES , just unbelievable !!!!! I read that sometimes they have to do even up to 3 or 4 cuts to finally make it loose enough and that many times cut is made insufficient and also they sometimes cut wrong tissue all together

Hallelujah !!!!!!! May this second round bring you the final and complete healing, Juney !!!!!Yeeeaaaayyyyyy !!!!!!