Hello all, I'm new to the forum but already incredibly grateful to all of the folks here who have written over the years. This is an excellent resource for a very debilitating problem.

I've attempted to peruse the archives and stickies for answers to a few questions I have with no or limited luck. I was just hoping for a few quick answers or even links to help if I've missed something. Happy to delete this thread if I am being seriously redundant.

Thirty second version for context: I'm late twenties, was recently diagnosed (~10 days) w/ an AF based on consultation w/ a CRS. Have suffered from hemorrhoids in the past so assumed (and was told by my GP) that the pain I started experiencing about 6 weeks ago was related to that. Mis-treated w/ Prep H, Colace, and suppositories. Have now been using 0.2% nitro (2-3x daily) and twice-daily psyllium (husk) supplement as recommended by CRS. Symptoms have improved only modestly, so now I'm exploring ways to sort of double down on my treatment. Pain is very sharp during BM, usually subsides for the most part post-BM, but within an hour returns in the form of pain/itch, and stays for most of the rest of the day in many cases (I am an AM BM - er). I am (was) very active physically and eat a reasonably healthful diet (now being super charged).

OK...

(1) Forum goers often refer to the internal spasming of the sphincter which nitroglcyerin ointment is supposed to help relax, in order to stimulate blood flow. I have never *FELT* this --- is the spasm something which is physically felt by the sufferer? If so, how would one describe it? What I mostly feel is a constant burn/itching sensation. If I am not experiencing this symptom, it would suggest the ointment itself is not necessary.

(2) Related to (1), it is unclear based on reading this forum how important it is to apply the ointment directly to the wound (internal in my case). I find it very painful to insert anything like this, and so I've been applying externally. I get the transient headaches, so I know the ointment is doing *something*, just not sure if it is doing what it is supposed to.

(3) What is the best way to counter-act the "plug effect"? This seems to be the worst aspect of my AF, because it is when most of the pain during my BM is experienced. I sit for 10-15 min to move the smallest amount, which is very painful, and then the bulk of the rest is only painful to the extent, I surmise, that the wound was just re-aggravated by the "plug" matter. As mentioned I am taking psyllium 2x daily with water (and Cyrstal Light), and this seems to be effective at cleansing the bowel/ colon (in the form of large BM), but with a side effect which seems to be, I am only moving 1x/ day as opposed to 2x (which was what I was doing when I took the Colace).

(4) Before I suffered this AF (which was caused, I believe, by a very hard stool several weeks ago, when I was out on holiday and likely very dehydrated due to weather conditions), I consistently took a fiber supplement in the form of fiber gummies (now I can appreciate how silly that probably was), *BUT*, I generally had a very *REGULAR* BM experience, besides a few random hemerrhoidal flare-ups. I would be in and out of the bathroom in 1 min at a very regular schedule. Constipation was not really a thing for me. *NOW*, it seems as though it takes 10-15 min to "get going" (ie the "plug"), which doesn't really make sense given that I am on the fiber, hitting the probiotics, etc. Perhaps this is just a psychological aspect of AF --- it would be "easy" to go, except a lot of pain is being caused, so we try to *COAX* and squirm our way through the BM. Does this resonate with anyone at all?

The reason I ask is because I am wondering if hemerrhoids may still be an interrelated cause/effect of my condition (the CRS did a visual examination, not anything with a scope), or something worse?

Thanks so much for any guidance or wisdom you all may be able to impart.

Hands-full


Clearly you have done a lot of homework...good on you. It's always helpful to be armed with as much info as possible. I will do my best to answer some ?s and I am sure others will add.

I too in my early days thought I did not have spasming but an intense burn and pain with bm. I have now come to understand that much of my burning feeling was and is in fact the sensation of the spasm. Perhaps it is the same for you. Even if you don't feel or don't have a spasm it is still useful to use the creams - essentially they lower the resting pressure of your internal sphincter thereby allowing more blood flow to the area. Blood flow helps in the healing process...so there is utility to keep on using.

I too was initially told to insert the cream on the wound - NOT necessary. The active ingredients are well absorbed by applying around the anus.

The dreaded plug...for some of us it seems no matter how much water we drink, how much fibre, fruit etc we eat we always get the plug....my only solution for that is miralax.

Yes...your experience resonates. Before my af I would go without hesitation and usually very loose. Since af it has all become more difficult....stress is the culprit I think. It is amazing how stress hormones coursing through your body can play nasty games with your gut and your emotions.

I hope some of that helps. You are doing great - try not to overdo the fibre - no point in bulking up the bm so it is difficult to pass. Lots of water, baths or sitz baths and heating pads all help.

Best -
Canadabum

Thank you Canadabum.

It does not come as a surprise to me that stress also plays a role in this whole thing, as I have had a somewhat modest increase in stress (and have been working 70+ hr/week for most of the last half decade). It is a good reminder anyway that life is short and health is precious.

I am going to do my homework on Miralax and perhaps try it, and/or possibly restarting usage of the Colace.

Thanks again.

Welcome to our Forum, hands_fullo47,

Great to hear that you don't have spasms, which if you've read about this of us who have done/ do you will realize are nasty to have. Similar to having a baby, but just every day, and continuing for hours.

I took Colace for a time, but did not like it, so would go with CB's suggestion of Miralax. Colace, for all its supposed properties of softening the stool worked in the opposite way for me.

You don't actually want to have large BMs, you just want them to go through smoothly. Fibre needed is 25g for a woman and 30-35 grams for a man. Also, would suggest that you don't overuse soap, wipes, other creams, etc. I very seldom use soap, never ever rub after a BM, use a Sitz Bath to soak, and spend a fortune on cotton sterile swabs to clean, very very gently with water after a BM. if you have only had the itching since starting with the GTN, it may be a reaction to this. If so, there are other creams/ointments such as Diltiazem or Nifedipine that can be prescribed. If it continues, I might suggest an irritation to something or the possibility of a thrush like 'infection'.

Would join with CB too, that you most definitely do not need to insert the GTN; it will enter the bloodstream quite adequately from being used externally - and save you the stress and pain...

The hard bit at the start of the BM is generally caused by the spasming of the internal sphincter, so even though you might not be having that much pain, I would suspect that and try the Sitz Bath.

70 hours a week's work! Ugh!! Hope you can reduce that slightly.

In my early days on the forum, I asked the spasm question too, because I didn't think that I experienced such a thing. I discovered that a spasm doesn't necessarily "pulse" on and off and that my type of spasm was perhaps more of a one time clench that just stayed in that position. Mine fissure pain felt like a blow torch was aimed at my butt hole and was on full-blast for many hours after each BM.

I only used diltiazem, and it never helped with the pain, but my doctor had told me (incorrectly it seems) that it wasn't supposed to help on that front, but was an ointment that would encourage new blood vessels to grow and increase blood flow in the area so that the fissure could have a chance to heal. After reading on this forum, and seeing how others did find relief with diltiazem, I learned that it can also ease the spasming for some. My doctor also told me not to insert it inside, because it would be easily absorbed from the outside.

Savaici and Chachacha, thank you for the additional perspectives.

The itch has been a symptom throughout this experience, and not as a reaction to the GTN. Since beginning on the GTN+Psyllium (plus ratcheting diet), the main thing I can say in terms of improvements:

+ BM is no longer bloody upon wipe (unless I happened to get confident and eat something I shouldn't have)
+ The pain reaches less *extreme* levels than it had before --- less instances of having to go and lie down, less "pull my hair out" spans of time
+ But the pain is still relatively consistent, in the form of an ongoing itch/burn for several hours post-BM, and, it is still relatively "variable". I.e., During a BM, the pain is minor to modest, immediately following a BM, the pain is typically minor ("I'm OK!!!"..), then on and off it will increase and decrease in intensity for the next few hours ("Here we go again.."), rinse/repeat.

I'm optimistic that this will all be cleared away in a few weeks but I can also appreciate based on folks' perspectives on this board, this can be a much longer heal cycle.

I'm optimistic, no disrespect to those who have suffered long and hard, that I am not towards the most extreme end of AF's, but in any case we will just have to see...

Thanks again.

I would be optimistic in your shoes too. I will also say that my blood never seemed to be related to pain at all. I could have many very bloody episodes with no pain, and extreme pain without any blood at all. And then I would also experience the exact opposite. None of it ever made any sense.

Good luck, hands_full.

Hi, metamucil is not good for a fissure. It's a bulking fiber thus it makes your stool larger. It may be soft but it's hard to expel when your muscle is in spasm. I would recommend miralax or milk of magnesia.

Thanks all.

Question: is there a way to make any kind of a small donation to support the efforts of this site? I'd be interested in doing so if that is being accepted. This is a vital source of information and camaraderie for folks suffering from these conditions.