Hello good friends,
2 months ago I was celebrating that my fissure problems were gone... And I did have 6 dreamy weeks with no pain whatsoever and a cured fissure through the regular Nifedipine etc medications, really back to normal life... However, a sequence of hard BMs set me back some, and here I am again to ask your thoughts.
So I've been having some bleeding and moderate pain after BMs in teh past 3 weeks. The pain isn't really that bad, it's a dull ache 1-2hr a BM and which lasts for 2-3 hours. However, given the blood, I went back to the CRS.
I was so "tight" and anxious given the setback that she said she couldn't really exam me too well. In the past, she could see the fissure very easily, but this time she couldn't see it. This was a good thing and made sense considering that I don't have the fissure pain like I had before. But anyway, she recommend an exam under anesthesia to check whether my fissure is back or if this is "just" hemorrhoids.
She also asked me what would I want to do during the exam as she could treat some of the stuff since I will be knocked out anyway. She said she could do a LIS, Botox and a rubber band ligation if she finds hemorrhoids.
I'm still thinking about it. She said herself that my fissure was't deep or long and was pretty external, and I had another doctor before recommending against a LIS for it. My current thoughts are around authorizing a Rubber Band ligation for hemorrhoids (pretty safe and effective procedure as it seems) and Botox in case she sees a fissure. Although I know that LIS is very effective, given my low pain (it goes away COMPLETELY 2-3 hours after a bowel movement, and all that happens when I'm in pain is that it's uncomfortable to sit), I think I'll be conservative.
She also said that this second episode could actually be "just" internal hemorrhoids with some levator ani problems given that my pain is dull, goes away, improves when I walk and is more prevalent on the left side. I used to feel this when my fissure was very acute, but I was mostly focused on the fissure and not this pain before. She gave me a muscle relaxant in the hopes this would address the levator ani and let the hemorrhoids heal themselves.
Any thoughts from people here? :)
Thank you!

Hi Dan,
So sorry to hear you have had a setback.
Gosh, there is so much to think about, and you have options to consider. Of course, the first thing on the list is to get bowel movements soft and easy to pass again regardless of surgical decisions.
Since you've been fissure prone in the past, the concern I would have about only treating a hemorrhoid situation should there also be a fissure (or even if there isn't one currently) is the possibility of more tightening of the anal canal following a procedure for hemorrhoids alone (without LIS) that will either delay healing of a fissure if you have one now or cause you to be at even higher risk for developing a fissure after the hemorrhoid procedure.
While I understand the logic of consenting to a procedure before you even know what you're dealing with because you're already under anesthesia, if it were me I would want to make a fully informed decision by doing it in two stages. First the exam under anesthesia and discussion of the findings and options, and then a second procedure to actually carry out the plan.
Of course, no one else can know the level of pain you're in and how decided you are about having any procedure performed, but any chance of giving conservative measures a try while getting BMs soft again?

Hi Dan,
Sorry to hear you have had a set back
I would second what jr2 has said. I would find out what is going on down there first. It's best to know all the options first before making the right decision.
Omb

Hello all, thank you again for the quick answers and valuable insights. My stools have been great in the past 3 days, I still debate with myself which changes got my soft stools back, but I have 2 very likely candidates:
1) I had an impression that I was resisting urges after dinner and thus this was giving me hard stools in the morning. I relaxed at bit at night and gave a try to having a 3rd BM every day
2) I started softening the brown rice I eat daily with water prior to eating
Either way, things have been much better in the past days when it comes to stools.
I gave the muscle relaxant a try yesterday and this morning, and I can only say WOW. The pain I was feeling really went away very quickly. I was suspecting that this dull pain wasn't really fissure pain, and maybe it isn't indeed. It really matches the descriptions of levator ani syndrome and the muscle relaxant working is yet another indication.
I still have a bit of blood coming out, but I don't have enough data yet to evaluate this part since I just started taking the medicine. Levator ani syndrome won't make you bleed, the dr says, so obviously there is something else - fissure or hemorrhoids. My experience with fissures is that there is no such thing as a "pain free fissure", although my fissure was nowhere near some I've seen in this forum in terms of pain.
I think that your perspective is very interesting. I'm really tempted in authorizing the banding of the hemorrhoids if I decide to go for the EUA since this is a generally safe and effective procedure for internal hemorrhoids. I didn't know it could delay healing a fissure, though. But the new insight here is that it might not make sense to authorize Botox or LIS before thinking it through.
I'm actually really, really not liking the idea of authorizing the LIS given my low pain level (even before the muscle relaxant) and the fact that I already cured a fissure conservatively twice (1 week first time 10yr ago, 3 months second time 2mo ago - and if I did have it a 3rd time now, it might even be cured already after just 2-3 weeks).

Hi Dan,
Yes, banding is generally a safe and effective procedure. Some surgeons say a small percentage of people can develop anal stenosis that seems to be slightly higher when multiple hemorrhoids are banded at once. Anal stenosis may make a former fissure sufferer more prone to developing a new fissure or worsening an existing one. Furthermore, a small percentage of folks actually develop an anal fissure as a result of the banding procedure and subsequent falling off of the hemorrhoid tissue.
Given that you don't know what you're dealing with or what exactly you are consenting to, if it were me I would just want to know before I consented to anything. But if you have a high level of confidence in your surgeon, and feel really comfortable consenting to the banding, that is totally an individual thing.
So glad to hear you are feeling some relief with softer BMs and with the muscle relaxant. While levator ani syndrome alone does not cause anal bleeding by itself, the tightness of these muscles can impact the muscles of the the anal canal which sets up a scenario for the fissures and hemorrhodal problems. If your surgeon suspects with confidence that you do have levator ani syndrome it would be in your best interest for them to refer you to a physical therapist in your area to be evaluated for physical therapy to rehabilitate the pelvic floor muscles.

jr2, you always have a lot of awesome info, thanks again :)
Yeah, I've thought about some of these things. My CRS is in theory great, she's very skilled and respected. But she's also one of those doctors that won't recommend a thing, she will be like "we can do X, but Y can happen. We can also do Z, but W can happen". At the end of the day, she's basically asking me to make a call on treatment. I guess this is good from one perspective, but at this point I'm not loving it too much.
I liked your point about levator impacting the tightness and then triggering fissures/hems. I thought about that but couldn't find reliable information online stating what you just said - that the extra tightness could trigger bleeding hemms. It makes sense, but I'd like to read more about it if you know of a good source!
Here's one odd thing. I said I was doing great and then this thing restarted. It actually restarted after visiting my CRS for a "post healing checkup". I was all smiles and cheers. And then she said "look, if ever bleeds without pain (a complaint during my fissure days), maybe we should do a colonoscopy". This actually made me very anxious - in the next 3 days I was all tense and that's when my bleeding restarted. 1 week later, I think the fissure reopened (and for now it is closed it seems)...
Either way, I tend to be minimalistic when it comes to my health. I'll try the relaxers for a few weeks to see where it takes me. If things don't improve (I had a great day today, little pain and no bleeding), I'll go for the EUA...

I am going to add that all my af trouble started after surgery for hem banding and skin tag removal. I am now undergoing phisio for pelvic floor to try and get the resting pressure down. My pelvic floor consultant said that she wishes consultants would send patients for pelvic treatment before considering any invasive surgery.
Wish I had known this before!
Keep using the relaxers if you feel they are improving things. What are you using?
OMB x

Hello omy, I'm using Robaxin (actually the generic Methocarbamol). I'm already 2 days without bleeding or significant pain, started helping right after I started taking it, and I'm not even taking the full dose yet.
Coincidentally, my previous healing happened when I was out of the country, with my family, and getting help with our hyperactive 3 year old :). Maybe stress does play a huge role in this condition...
What symptoms do you experience? Do you have the dull ache that starts 30min or so after a BM? How long does it last? Does standing make it better?

owmybum wrote:I am going to add that all my af trouble started after surgery for hem banding and skin tag removal. I am now undergoing phisio for pelvic floor to try and get the resting pressure down. My pelvic floor consultant said that she wishes consultants would send patients for pelvic treatment before considering any invasive surgery.
Wish I had known this before!
Keep using the relaxers if you feel they are improving things. What are you using?
OMB x

Yes, pelvic floor retraining can often be quite helpful!!

Hi dan,
I have not heard of robaxin.... Is it cream or tablets?
I too find that my af gets worse if I am stressed. I have an 8 year old who is autistic and he is hard work... So I can understand that having help on a break away from home would take the pressure off with a young energetic child!
I don't get horrendous pain when having a bm anymore, but I become sore and achy about ten mins later and it usually lasts all day. I find standing makes things worse but walking about isn't too bad. It depends if my sentinel pile is playing me up!!
OMB x