I'm a 37 year old male with a ten year history of chronic rectal pain that is said to be caused by spastic levator muscles and/or pudendal neuralgia. About 7 years ago I developed fairly mild internal hemorrhoids and also began to develop recurrent external hemorrhoids, some of which became thrombosed. My CR has never suggested surgery for the hemorrhoids and still does not believe that they warrant invasive treatment, and I agree. About 4 years ago, I developed my first anal fissure. With very conservative treatment, the fissure healed within a month and I did not have another recurrence for over 2 years. However, since that time, I have developed 3 recurrent fissures, each about a year apart and all of which have healed within 4 to 6 weeks with conservative treatment. I am now dealing with a new fissure for the past 3 weeks that does not seem to be getting better. I have an appt with my CR next week for a proper diagnosis. My local CR will not perform LIS because he feels that the risk of incontinence is too great and he doesn't feel that botox is very effective. His surgical treatment of choice is fissurectomy. But, given the fact that I have spastic rectal muscles, even when I do not have an active fissure, I don't really see how a fissurectomy would help me long term. So, I have visited the Mayo Clinic in Phoenix and they do offer alternative therapies such as botox and LIS. I have also corresponded with a CR in the Dallas area who believes very strongly that I would benefit positively with LIS. He has gone so far as to say that it would eliminate my recurrent fissure disease and that the procedure would be very simple and the recovery time very short.
So, I have a big decision I need to make very soon. Once I see my local CR and get a diagnosis, I will need to decide how to proceed. I can do conservative treatment to see if it will heal as the previous ones have, I can go back to Mayo and do either botox or LIS or I can go to Dallas and have that CR perform LIS. One other note to consider is that for the past several years I have had what is described as evacuation constipation, which means that I am very regular and my stool is soft, but my muscles do not allow for easy passage of stool. This is why I get recurrent fissures. So, in light of all of this information, I just want to get some feedback from the group on how to proceed. I'm leaning toward LIS, but I am really, really afraid that it won't work or that it will make my situation worse. The botox concerns me because I already have a history of thrombosed hemorrhoids and I'm afraid that the injections would cause another thrombosis. Any suggestions would be appreciated.

mm,

I think you can have the levator muscle injected with Botox or electrically stimulated but not sure if it's a permanent cure, with regards to the pudendal neuralgia, they can give a nerve block steroid injection or even surgery called Pudendal nerve decompression - see www.pudendal.info for more..
About the hemmorhoids: I cannot understand why a CRS wouldn't operate on thrombosed hemmorhoids, a few people on here have had hemmorhoidectomies and even I've had mine injected and banded, so why he won't operate is completely beyond me I'd seek a second or even third opinion on that.
re the fissures, I would opt for LIS hands down, Botox doesn't seem to have quite the success rate, I can't see why it would make you worse than you already sound, but I'd definitely seek another opinion about the thrombosed hemmorhoids, I'm no doctor but they need removing IMHO. Maybe you could get both procedures together like Philber has (Hemmorhoidectomy and LIS) he doesn't regret it and is well on the road to recovery.
Best of luck with whatever you decide, hopefully some of the other boardies will chirp in soon with their thoughts. You can read Philbers surgery story here: http://anal-fissure.org/considering-surgery-or-already-had-it-f1/sphincterotomy-and-hemmorhoidectomy-four-days-ago-t2348.htm

Sorry to hear that you are suffering so much : (((
Your case is VERY complicated and if you can afford to go to Mayo, than definitely go there since they will at least do that LIS in the best possible way.
I agree that fissurectmy alone would do nothing for you.
If you have such strong spasms , than LIS would be the most probable lasting cure BUT - you might have some neurological problems also, it seems ,that prevent your colon to evacuate at times Did anybody ever look into that ??? Do you have that evacuation problem even when your fissure is absent ??? :roll: and you have no pain ???
On the other side, LIS would make your sphincter more relaxed and possibly help with it opening when necessary without a problem. The only thing is- OUTER sphincter - one that is in a shape of a ring and one that you see when you touch your anus IS THE ONE who can actually be the "stubborn" one in your case *sigh. Now- nobody should tamper with that one since it is the one that has a final say in what is going out and what not . That is why "anal stretching" is more risky than LIS .
I really can only say that you should be treated with the best doctor team that will do all possible examinations , including manometry and X-rays during evacuation to see in what way your muscles do not work ! If you have functional problem than your doctors might want to look into pelvic-dysfunction treatments and not LIS :roll:
I wish I could be of more help Please do not rush into anything until all in depth tests are done for you since you are not a typical case

Thanks for the responses. To answer some of the questions, my chronic rectal pain started over 10 years ago and was not the result of fissures, hemorrhoids or any other diagnosed anal/rectal disease. Initially it was thought to be due to an issue with my prostate, but later it was generically diagnosed as chronic pelvic pain syndrome. The internal/external hemorrhoids did not begin until 2 or 3 years after the onset of the chronic pain and the fissures didn't begin until about 4 years ago. My internal hemorrhoids are only considered grade II and I believe that surgery is reserved for grades III and IV. And, my external hemorrhoids, which have become thrombosed at times, are very sparadic. I have sometimes gone for more than a year between episodes and they typically have subsided within 10 days or so. There was one time back in 2005 where I got a really big bad thrombosed hemorrhoid and I did have the clot cut out, but even that minor office procedure was difficult to recover from.
My levator spasm and rectal tightness is present all the time, not just when I have an active fissure and my difficulty with bowel evacuation is the same way. And, when I say that I've had chronic rectal discomfort for over ten years, I do mean CHRONIC, in that it does not come and go, it is always present. I have visited a pelvic pain clinic in California where I had two rounds of nerve blocks and several other types of injections, but they didn't offer much improvement. I've had lots of tests, all of which were negative. I've also undergone weeks and weeks of physical therapy to try and get the muscles to relax, but that hasn't done much either. I have not had manometry or defacagraphy study, but I've had both tests scheduled, but I was told that neither study would be accurate with an active fissure. Anal pressure is always higher when a fissure is present, so the doctor didn't want me to have it done until my fissure healed.
I know this is alot of stuff to take in, but this has been my life the past ten years and now I'm trying to figure out the best way to deal with the fissure issues and then I can tackle the underlying problems.

I'd agree 100% with Fissulyna as far as figuring out the underlying cause before doing anything.
As some of the folks here know, in most cases, I'm personally a fan of trying Botox before LIS. Although not as effective, it's also less permanent and there's not much to lose by giving Botox a go IMO. I got great results from Botox, it's just that it didn't last. But I'm glad I did it before having surgery.
But in your case the clinical picture definitely seems very complicated, and I'm not sure any conventional wisdom or standard approach is going to be the right suggestion To be honest, the fact that you had a hard time recovering from your thrombosed hemorrhoid procedure might even be more of an argument against surgery and in favor of trying Botox first despite the (very minor IMO) risk of it causing another hemorrhoid.
I should disclaim that my view is skewed by the fact that I didn't have a very positive experience with LIS though (however my situation may be more complicated than I initially thought too).
What kind of injections did you have done in California? Was any of it designed to relax muscles, or was it all strictly nerve blocks?
I guess what I'm trying to say is that reading through your post, I just don't get a very strong feeling that either Botox or LIS would be the right thing to do here based on the available information. Can they do any other tests like a MRI or ultrasound to see if you have any pelvic or rectal muscle damage? I don't think it's possible to have too much information when there's this much going on.

The general consensus among several doctors that have treated me is that I have dysfunctional pelvic floor muscles, including the levator muscles and sphincter muscles. This has led to rectal discomfort which in turn has led to difficulty with bowel movements which has led to psychological issues that has just served to make all of these issues worse. Unfortunately, there isn't a single type of treatment for pelvic floor dysfunction. It's more of a trial and error approach. So far, most of the treatment that I've received has not been effective. The longer this continues, the more my mind is destroyed and the more anxiety I have during bowel movements, which just makes matters worse. The problem with the fissures is that I cannot receive treatment or testing for the underlying cause while I have active fissures. I have had to wait for the fissures to heal before continuing with treatment for the underlying cause. This time, however, it does not seem as though the fissure is healing because I just can't relax to use the bathroom. So, I'm left with trying to figure out what to do to resolve the fissure issue. I'm about as low as I can possibly get right now.

I would try seeing a psychiatrist to get started on an A/D to get out of the vicious cycle of mental and physical suffering. The Pelvic Floor Retraining Class would probably help you if you have pelvic floor dysfunction like I did. Some people take the anal manometry class while having a fissure, but I think that would be difficult to do.

Oh my "mm", I wish we can help. Listen - I can only tell you what I would do if I was you *sigh. I would try Botox before the LIS since although it can cause some side-effects they all are reversible and it will give you the much needed info - is relaxing your internal sphincter of any help with your condition ??!!!
BUT - I would than go to a CRS who is extremely experienced with Botox administration and knows where and how much to administer since if he misses the muscle or gives you too little , than you will NOT have definitive answer.
If Botox helps you with symptoms - than you can repeat it 3-4 times till you heal. If you re-tear soon after than LIS is definitely IN as an lasting solution :roll:
How about that plan :D ???

I think it is a good plan, but I would need to find a doctor who is not only familiar with botox injections, but who has a good deal of experience with it. This wouldn't be a major issue if I didn't live in New Mexico. This is not the place you want to be if you have these types of problems. Only 2 colorectal surgeons in the entire state and neither of them recommend botox or LIS. I think I could get botox at Mayo, but aside from that, I don't really have any other good leads. I just hate that I have to incur all the time and expense involved with traveling out of state for treatment that I should be able to get at home. The doc I found in Dallas does not do botox, but he sure does sound incredibly confident that LIS would make a big difference with me. I'm afraid for the reason that you mentioned which is that LIS cannot be fixed, but botox is only temporary. I'm just not sure I want to spend all the money involved in traveling out of state for botox. Maybe I can keep searching locally.