If I knew then what I know now...


I am not a doctor and individual results are very likely to differ, but I want to share some key learnings for me.

Though I likely had an anal fissure for the past 20 years, it became a serious problem 18 months ago due to constipation upon starting a new set of medications (Truvada and Wellbutrin). In addition to the fissure I had hemorrhoids and an external skin tag.

I tried many constipation remedies with mixed results:
- Magnesium Citrate (600mg) - had the best result
- Colace (200 mg) - 2nd best
- Prunes (12 daily) - good results but lots of calories/sugar
- Coconut Oil (2 tablespoons daily) - helped at first but stopped working
- Miralax - no impactAlign probiotic - I still take but don’t know if it does anything
- Fiber - tried Metamucil and citrucel. More on this next

I had the following treatments:
- Rectiv Nitroglycerine gel - used for 9 months
- Hemorrhoid removal
- Botox (2 sets of injections)
- LIS w/skin tag removal - followed by 3 months of a nitro/lidocaine/zinc/vitamin E ointment sold by my Dr.

It has been 3 months since the LIS and I believe that I am now functionally healed. Here are a few of my key learnings:
1) Solving the constipation is the #1 priority. Find what works to develop soft stools consistently and stick with it until fully healed (see below for how to tell if you’re fully healed). I would find that different remedies would cause me to get stomach pains, have BM’s 5x/day, etc and I would stop the treatment. This would result in a fresh wave of constipation and a re-tear of the fissure. Had I kept my BM’s soft until I was healed I may not have needed LIS.
2) Fiber was a major cause of constipation. I have been taking Metamucil (5-6 pills/day) for the past 15 years. I recently realized that since starting on my new medications 18 months ago, the fiber has been having a different effect on my digestion. Specifically, it was causing me to be constipated with hard and lumpy stool. Since stopping fiber entirely 2 weeks ago I have not had to use any constipation remedy and my stool remains soft
3) How to know if you are fully healed: As a gay man that practices receptive anal intercourse, I consistently was trying to determine if my fissure was healed enough for sexual activity. Inevitably I was too impatient and would get an even worse fissure upon attempting receptive penetration. It is critical to have patience and wait until you are fully healed before making any penetrative attempts. For me, I knew I was fully healed when I had zero pain from the fissure site. To be specific, I had 3 causes of pain/tenderness:
3a) From the fissure itself: To test whether the fissure is healed, insert a finger into your anal canal and gently press against the rear wall (where the fissure is). You should be able to exert a fair amount of pressure without feeling any discomfort or pain. IF YOU FEEL ANY PAIN DURING THIS TEST THEN YOU ARE NOT HEALED
3b) From the LIS surgery site: It has been 3 months since my LIS and I still feel a tenderness from the surgery site. This is normal and not an indication that you are not fully healed. You should be able to press externally on the site (mine was adjacent to my anal opening) and replicate the tenderness/soreness to confirm this is where any discomfort is originating. For me, I could have receptive anal sex with tenderness from the surgery site as long as there was none from the fissure itself (as described above)
3c) From an external rash: Softening my stool caused me to have more BM’s and wiping was more challenging, causing an external rash/sensitivity. My recommendation is to be very gently when wiping, use wet toilet paper (or baby wipes) when possible, and don’t be obsessive with cleaning (2-3 wipes max). I have also used aveeno lotion externally

It is a long and depressing (at times) journey, with many nights googling for answers (how to treat constipation, how do I know if my fissure is healed, etc.). I share these tips because if I knew then what I know now, I may have been able to minimize the healing time.

This is really useful information. Thanks for sharing! Do you happen to live in San Francisco? (Since your username has SF in it) I'm looking for a good specialist in the bay area and it would be helpful to get some names.

I'm glad you found the information useful. I went to the Center for Colorectal Health on Sutter in SF. The doctor specializes in fissures/hemorrhoid so has a lot of experience.

Were you treated by Dr.Million? And does she do Botox injections with sedation?

Yes, Dr. Million did the Botox but I didn't have sedation. Regardless, it wasn't a terrible experience. A few quick shots and she was done.

I have just joined the site and as a gay man too I found your post to be both helpful and reassuring as the past couple of years have seen my life turned upside down with haemorroids leading to skin tags leading to an anal fissure.
I have just had botox a couple of weeks ago as diltiazem didn`t work so I`m hoping this treatment will work as not being able to have had sex of any form for nearly a year is making me so depressed. Unfortunately I live in the UK and my experience of doctors here is that they are quite homophobic and unwilling to discuss any issues around sex. I work as a flight attendant and so come to SF occasionally. Do you know if it might be possible to see the doctor you mentioned at the center on Sutter (I appreciate I will have to pay as an overseas patient) since simply talking to a medical professional openly about the sexual issues around rectal problems will be a god send. Thanks

You can definitely go see the doctor in SF, but be prepared to potentially pay hundreds of dollars out of pocket. You'll also need to call and confirm beforehand if they will see a patient without insurance. I personally wasn't happy with the doctor because of her eagerness to use an anoscope on me when I was obviously in pain already. I refused to let her use it. Her office never got back in touch with me about scheduling an MRI either. If you do go see her, remember that you're not obligated to give in to any examination.

I’m glad you found the post useful! I’m not sure of the situation/cost without insurance, but I would more highly recommend trying Dr. Jeffrey Sternberg instead. https://www.pilonidalsurgery.com

Since my original post I had hemorrhoid issues and wanted removal of a skin tag. I don’t want to go into specifics about doctors, but I would no longer recommend the center on Sutter.

Thanks so much for getting back to me. Friends in NYC have actually just recommended a gay surgeon there who friends of theirs have used and has extensive experience in this area. I`ve made an appointment to see him now in a couple of weeks but I will keep the option of Dr Steinberg open for the future just in case.
I actually went to see a private doctor here in London as I was so desperate, it cost me the equivalent of $1000 but he was totally unhelpful and homophobic, consequently I won`t begrudge paying to see someone who will, hopefully, be more helpful in the US

who is ur gay surgeon in NYC.... been to a couple there...