First, some background. I have been suffering from AFs for more than 13 years. I am not a doctor or a medical professional, and I am not writing this post to convince anyone of anything, but just to provide some information that might be useful to others in a similar situation – just as I found information from many others very helpful as I was going through this. For additional background, and those not familiar with SAD – standardized anal dilatation, I suggest reading at least the beginning of this thread by wecc first: http://anal-fissure.org/my-standardized-anal-dilatation-this-morning-t4104.html. I use the terms dilation and dilatation interchangeably – I think the doctors use ‘dilatation’ vs. ‘dilation’.

I first got AFs when I had my wisdom teeth out and was given some very constipating medicine for the pain. Since then, I have done a LOT of research (and probably forgotten at least half of it) – I have tried nitroglycerin, lubricants, some self-dilation etc. and I had grown disillusioned with the ‘professionals’ early on because it seemed I knew more than some of them did – I had to push one of them (showing studies etc.) to give me the Nitro, and that was after I convinced him to check for AFs! None of the alternatives worked for me. I have been able to manage the pain with magnesium supplements (after trying a lot of alternatives like stool softeners, mineral oil etc.) – I would say even get it to ‘heal’ where there was no blood or pain, but over time I began to think I should look at something else as I didn’t think it was fixing the root of the problem and I would have constant flare-ups where pain levels would skyrocket to a 8 or 9 out of 10, and then take a week or more to get under control with increased magnesium. I mean really, forget waterboarding – if you *really* want to torture someone, give them an AF! :)

Over the years this condition has really impacted my life and I finally decided that instead of maintaining the course and worrying about the “what if something went wrong scenarios” to think about “really getting my life back” and doing either the LIS or SAD. After reading posts on this forum, and others, decided that dilation was what I wanted to do as it had the least risk of complications, even if I was giving up a slightly greater chance of a complete cure with LIS.
I live in California, and tried to find a CRS who would do the procedure, but when I called their offices, they didn’t want to answer any questions other than book me in for an appointment with the CRS. And when they did answer, they didn’t understand what procedures the CRS did - and when they did manage to get an answer from the CRS they were told that dilation was archaic, dated, and/or not the gold-standard like LIS is.

From my research I knew about the CRS in NY that did the SAD procedure and had learned some of this from Dr. Sohn (from my research, I knew about Dr. Sohn who had been re-visiting the use of SAD in NY, but I had not given up trying to ‘self-heal’ or ‘self-manage’ by the time he retired – see: http://www.thedoctorschannel.com/view/a ... -fissure-3). I setup an Internet chat session with the CRS in NY and after speaking with him, I thought he knew what he was talking about. He did not push SAD at all – just stated the facts and that included his feeling that cure rates might actually be a few percentage points lower than LIS, but that since the risk of complications are vastly reduced, SAD is the only procedure he does now. To confirm I had an AF, I saw a CRS in California who confirmed the issue, suggested either Botox or LIS as the gold standard – when I asked about dilation she said something about it being an outdated procedure that just tears the muscle fibers. But then when I asked her about her patients who had complications from LIS, she said it would take several weeks to recover, and that she had some patients who had complications, including at least one who was very sick to begin with and became incontinent (developed an infection) – don’t get me wrong…I think she was a good CRS and had good reviews…had done more LIS procedures than most and probably very good at it, but she still didn’t know anything about SAD.

So I made travel plans to NY with my wife (she has been AMAZING in supporting me through all this, and I needed her to check me out and drive after the procedure – at least we made a mini-vacation out of it and saw a bit of NY :)) and arranged to see the CRS in the morning for a consultation, and then have the procedure in the afternoon. In the morning, the CRS confirmed I had the fissure, and we proceeded as planned. He said that he would do the standardized dilatation, and also do a fissurectomy – which does not really cut away the fissure or scar tissue etc., but mostly just cleans things up around the wound such as skin tags etc. and that helps it heal.

The worst part about the procedure (and the part that hurt the most) so far was probably doing all the enemas. I had to do two before the morning consultation visit, and one when I got to the hospital. At the hospital, there were the routine checks, questions, paperwork etc, and I was given an IV drip. I was told that I would be given local anesthetic, but would be sedated. So after all of this, I was taken to the OR room, asked to lie face down on the OR table in a “superman” position. Next thing I know, I was waking up in the recovery room – felt pretty good actually, and did not have any major discomfort through all of this. After some more checks, a light snack, and instructions, I was discharged from the hospital. Total time at the hospital was around 4 hrs – with 30-40 mins being the actual procedure, and the rest being prep, recovery time etc. I was given some medication (Ketorolac) to keep any inflammation in check, and asked to drink plenty of water, take stool softeners etc., and also given a sitz bath device – basically a shallow bucket that you fill with hot/cold water and sit in.

Well, since we were in NY, we decided to check out the town and ate a lobster dinner at a nice restaurant – yes, I was walking around town the same evening after I had the SAD in the afternoon! I had some “packing” taped up down there after the procedure which made walking a little strange (a bit like wearing a diaper I suppose :)). I was pretty comfortable for the most part – just felt a little numb down there, and the only surprise was really that I couldn’t control passing gas while I walked – it just came out really easily. I had to catch my flight back to California the next morning, so the morning before the flight I took off the packing down there (there was some discharge etc.), cleaned up in the shower, and then put on a pair of depends I bought for the flight at the local drugstore (just in case) – turned out it was a good idea because there was some minor bleeding/discharge by the time I got home.

So I had the procedure on Monday afternoon, flew home on Tuesday morning, and had my first BM after the procedure on Wednesday morning. By Tuesday morning, I had no issues with controlling the passing of gas, and by Tuesday evening, there was no more bleeding or discharge. I was a bit worried about this first BM on Wednesday (after eating some good food in NY :)), but it was only mildly uncomfortable – I had soft stools since I was taking fiber and magnesium – actually there was almost no pain and really no comparison to what I had gone through previously with AFs! After the BM it felt a little sore down there, but still nothing in comparison to the pain of AFs! I had a hot sitz bath in the tub for about 10-15 mins after the BM. Even though the pain is much reduced, it really helps to take time off as all of this can take lots of time – you don’t want to be rushed, push hard, be stressed etc. I had scheduled a week off from work, and am really glad I did.

On Thursday, I had the second BM. This time, I had a little more pain (like a 4 out of 10) – maybe it’s because I started reducing my magnesium intake….let me explain why. I think over the years I had ‘trained’ my muscles to work with the soft stools resulting from magnesium – I would be able to control the ‘size’ of the stool and the ‘way’ it passed through the canal to avoid pain and keep it manageable, but I don’t think this is how the muscles should ‘coordinate’ normally and naturally. So I’m trying to avoid that by keeping the stools a little bulkier (but still not too hard) to stretch out the muscles gently. I expect that will lead to some increased pain, and I’m trying to balance that so I don’t go too big/hard too fast. With the stool size today, I’m sure I would have been back at a 8+ level of pain before the procedure, so I’m still hopeful I’m on the right track. I had a sitz bath after the BM which really helped relax the muscles again. I’m still feeling soreness down there a few hours after though.

So that’s where I am today – not quite where I want to be yet, but very hopeful I am on the right track. I’ll make some more updates as I am able, but based on my experience so far it seems that SAD was well worth a try. My own opinion is that it should work for the majority of cases, is not very painful or uncomfortable, and can help avoid complications associated with LIS. For me personally, I wish I had done it years earlier. The main downside for me was the expense as I had to travel to NY with my wife, stay at a hotel, and there are insurance costs if you are out of network etc. On the bright side, at least I was able to make a mini-vacation out of it :)

Hope that helps, and just in case you see this posted somewhere else – it’s because I want others who may not visit here to know about this too.

I know the pain many of you must be going through, and how much it weighs on your mind and impacts your life, so I really hope this post helps at least a few. Here’s wishing you all the best on your road to recovery!

Pdox.

Great post, Pdox. Yes, wecc also had this done and came out fine. I considered it too, but just never quite made it. Maybe I missed it, but when did you actually have the SAD done? Will be interesting to here how things progress, so hope you will update us. Wish more CRSs would think outside the LIS box and consider SAD. I think part of the problem is a lack of training available for the procedure. By the way, I believe they do this at the Cleveland Clinic too, last time I was researching.

Good luck! Come back and give us your news!!

Hi Savaici,

I had the SAD done this week on Monday, Oct 21st. After the BM today (Friday - 4 days after the procedure), the pain level was around a 2/10, so not bad, but I think one problem was that the stool wasn't really formed at all, which at least for me sometimes puts increased stress on the area in terms of muscles contracting very urgently to get things out - I cut back on the Magnesium but I probably need to cut back more to around 250mg or less given that I'm taking a fiber supplement also. I'm also considering cutting out Magnesium completely if the fiber seems to be enough.

I agree - here in the US there is a lack of training around SAD. Most CRSs only know of the data/studies from manual dilation done decades ago I think and go to LIS because that's what is known and taught, and it does seem to be better than manual dilation. The CRS I went to talked about publishing a paper after he puts together all of his data, so maybe over time the procedure will be used more if the data is favorable...even if this happens, I suspect it will take many years though before it is more widely adopted in the US.

Will try to update here as things progress.

Good to hear that things are going well!

pdox gud to hear that u researched n decided to adopt different method. u r brave. that's gud that u r on the healing track. keep us posted so that AF sufferer in such countries where still SAD is practised they will b able to know what would happen n about the healing experience post op.keep posting. take care

How is it going pdox???

Thought I'd post a quick update since it is now almost 4 weeks since I had the SAD. Work and life is pretty demanding at the moment, but I'll try to make time to post here periodically.
After my last post on Oct 25th, I think I had a bit of a setback. I was trying to make the stool a bit bigger/bulkier to keep the muscles stretched, but I may have gone too far and the stool was too hard - had some bleeding the next day. The pain wasn't as severe as I had had before...maybe a 5/6, but the bigger concern was that the muscles seemed to have tightened up again almost to the point there were at before. The tightening may also have been due to a lot of stress at work. I got worried and called the doctor - he seemed to think there was no need for major concern yet, but I decided I needed to make some changes to avoid this going downhill again.
For one, it seemed like the muscles were tight again, so I decided to dilate at home. I started just using a finger (with finger cots and a lot of lubrication like Astroglide), but then I also ordered and started using the "Young's style rectal dilators" from www.toolsforsurgery.com. Before doing this, I asked the CRS who did my SAD whether there would be any issue with doing this, and he said that it should be fine and that I could try this if I wanted to. I'll go into this more a bit later. Apart from this, I also applied lubrication inside before a bowel movement, and whenever possible tried to be in more of a squatting position vs a sitting position - you can use a footstool or some object to rest your legs on a little if you can't squat directly on your toilet (I actually squatted directly on the toilet for the first few times, but I can't recommend this as it can be dangerous if you loose your balance). Another thing that might help if you can't squat is to rest your hands on the seat too and push down a bit with your hands so that they take some of the weight off your thighs, butt area when passing a stool. One other important thing I started immediately was sitz baths - I had never done this before as I thought that simply washing the area was the same thing, but there are other benefits. Not only do they help relax the muscles if they spasm a bit after passing a stool, but they also really help clean the area on the inside too (because your butt is actually under the water line), and I think keeping the area clean of fecal matter (on the inside too) really helps with the healing. I use it in the bathtub - fill the sitz bath with warm water, sit in it (so just your butt is in it, legs are outside), and then breathe in and out very deeply and slowly 20-50 times. When you breathe out, imagine/feel your sphincter muscles relaxing and opening. After you count to 20-50, ditch the water, replace with warm water and do the same again. Basically rinse/repeat 3-5 times.
After the sitz baths and dilating at home, things seemed to be on the right track again. I started decreasing my magnesium intake again and eating lots of fiber to try to get "normal' stools. I think that while the really soft toothpaste like stools may help get things back under control and even make the pain almost completely go away, in the long term they won't get you back to normal because your muscles aren't really working the way they should, and as soon as even a bit of hard or little larger stool comes along (which eventually always happened for me), things would tear and I would be back at square one.
Now to be fair, I don't know if things would have improved without the dilating at home, but I do know that the muscles had tightened up more, and I didn't want to risk it. With dilating, it is a bit of a balancing act, because you have to be very careful not to do more damage. That said, I don't think I ever did "more" damage when using dilators which were even bigger than any stool I had passed (I realize that seems counter-intuitive, and I can't claim to explain it, but I think this is related to how the muscles work). And when they do the SAD, the dilator they use is even much bigger. The Young's dilators start at 15mm diameter and go to 40mm (which is around the size they use for the SAD). I started with the #2 dilator which has a diameter of 20mm. It wasn't easy but I used lots of lubrication and went very very slowly. When I say it wasn't easy, it's not that the pain was like the usual AF pain (sharp, like glass etc.) - it was more of a dull/sore pain like I was trying to stretch my muscles that didn't want to at first, but after constant and firm pressure, they kind of give-in and relax - kind of like when a masseuse kneads a knot out of your back. If I ever felt too much of the sharp pain (like the wound might open up), I stopped. I do this every other day or so and I'm currently using the #3 or 25mm diameter one (I start with the #2, and then move to the #3). The way I do this is put a towel on the bed, lie down face up on it, and then slowly insert the well lubricated dilators. The entire process can take 30mins to an hour (if trying to go to a bigger size), and I like to leave it in there for at least 10 mins. Every time I dilated, the muscles felt much more relaxed and in general, I had a better feeling overall. Maybe for those of us with AFs, we store a lot of stress down there and this is kind of like an anal yoga :)
Over the past few weeks I have had semi-normal stools. When I say semi-normal, I mean what others would consider semi-normal...not the really soft mushy kind that the AF sufferers need to have to avoid pain/re-tearing. If I had any of these larger or bit harder stools before the SAD, I would undoubtedly been back at square one with all the pain. Today, I think I had a first completely normal stool - maybe about 20-25mm in diameter and there was some very minor pain (1/10) ...more like just a friendly reminder from my AF to not push things too far ;). I was actually a bit worried because I didn't have a bowel movement yesterday (changed diet a bit, and still trying to calibrate with less magnesium etc.), but things wen't surprisingly smoothly. What I find is that after so many years of having the AFs and using super soft stools to cope, my muscles have to "re-learn" how to pass a proper stool vs. the really soft/mushy kinds. I still try to rest my feet on a footstool if possible, try to relax my muscles as much as possible, and just squeeze/suck in my lower abdomen a little - I never push down on the bowels anymore which is hard to explain - I try to let the sphincter know it's time to open by bulking up the stool and squeezing with my abs a little, but it has to open on it's own - if you try to push through I think that's when the fissure might re-tear.
So to summarize, though I'm not completely healed/normal yet, things seem to be progressing in the right direction. I have almost no pain, and I continue to do the sitz baths (although I miss a couple now and then) and dilation. I plan to continue doing the dilation at home every 2 days or so until I get to the #6, which is 40mm, unless it starts to feel really bad for the muscles down there. It is uncomfortable when actually doing it, especially when going to a larger size, and I don't know whether the home dilation is needed for sure or not, but I think it makes sense that the muscles should be able to stretch to that size in order to eventually be able to pass a stool of that size. I think the SAD put me on the right path, and opened the window to enable me to do the home dilation -I don't know if I could have started doing this without the SAD, but it could be worth a try for those considering it.
I'll try to come back and post an update in the next few weeks or so. Good luck to all, and wish you speedy healing on whatever approach you take!
Pdox

Hi pdox, how r u now? hv u resumed ur normal diet ?