Patient 1

Patient 1

When did it start and what did you do about it?

When it first started out, I thought I was just having another case of bad hemorrhoids. I had had these off and on for probably 20 years. I usually got them after a lot of hard physical labor. They would go away in a few days and I would be glad. I would probably only get them once or twice a year and then maybe not for five years. But this was different. They did not go away. Kept bleeding too. This was a year and a half before surgery and the writing of this report so my details are sketchy. At the time, I was certainly under a lot of job related stress and I spent most of the day banging on a keyboard. Gee not much has changed in 18 months except the job stress is a lower. I go to a lady primary care physician and she says I have hemorrhoids and maybe an anal fissure. Boy the pain was incredibly bad. She said Sitz baths (sitting in a warm bathtub of water) would help ease the pain. She gave me proctofoam to squirt in the anal area. It is a foam with a pain killer in it and steroids. The pain killer was fine but the steroids really irritated the red area around the outside of the anus. I quit using the proctofoam due to the burning irritation and started using Diaper Guard, a white cream used for diaper rash on babies. I spent most of the Christmas holiday in the tub and started taking Metamucil with my meals and tried to eat lots of food with fiber. I cut back on my red meat consumption. I found that Ibuprofen helped a lot too.

I got better but decided to see a rectal surgeon anyway. He took one look at my rear and said you have a really bad anal fissure and most patients would have been in his office many weeks before. He also said that a patient with my size of anal fissure (10mm long by 5mm deep) would typically not be able to deal with the pain. I said I was dealing with the pain and it was getting better. He said stick to the high fiber diet and maybe it would heal up on its own. I had one a few years before and it had gone away on its own after I had taken a stool softener called Colace for a few weeks. I tried Colace at one point with this fissure, but it did not help. The one two years prior must have been a lot smaller because there was no trace of it at a follow up appointment two weeks after the initial diagnosis. The Surgeon gave me a 2.5% hydrocortisone cream called ProctoCream HC 2.5%. I think this is another steroid and it also irritated the surrounding skin so I only used it for a short time. The surgeon kept giving me the impression that it was only marginally effective anyway so not using it was not a big deal. I still would use the Diaper Guard from time to time.

So it did get better ever so slowly (Surgeon said it went to 5 mm long by 2 deep at the first six week follow up appointment). I would go back and see the Surgeon every month to six months and he would tell me it was still there and I would tell him it was getting better (it was down to 1 mm long at one point) and I would stick with the Metamucil and diet. Truth was it was always getting better except the few times it would get worse. Usually these coincided with hard physical activity but not always. And it did not always get worse when I had hard physical activity. I am not sure if it was the physical activity that was making the fissure bigger, or not getting enough water and ending up with a hard stool the next day. I combated this by drinking a tone of extra water (4 large glasses over a few hours) after all strenuous physical activity. I am an athletic male and so I would do this several times a week during my sport's on season.

Back to the diet, I only cut out all meats during the last few weeks and wish I would have tried this sooner to see if it would have helped. I would always have a high fiber cereal for breakfast Metamucil with lunch and dinner. Rarely would I have meat with lunch although I often had it with dinner. Looking back on things, I do think I lost ground after dinners we would have around special occasions and holidays that consisted in large part of red meat.

Many times I would only have occasional pain with a bowel movement and sometimes I would go almost a week without any pain at all. I thought this thing was going to heal up all on its own. About a year into the game, I figured out that using a Preparation H suppository at night before bed helped a lot and sometimes I would use one in the morning after the first bowel movement. My plan was that after a week with no pain, I would quit using the evening suppository. I just about made it several times. Rectal Surgeon kept being supportive of me continuing on my effort for a natural cure, but always added that I had had it long enough and he would remove it with surgery at any time I requested it.

So when and why did you select surgery?

Then about two weeks after no pain for a few days in a row. It got really bad. Back to the bath tub. Two or three Ibuprofen's per day and back to the Surgeon. This time, I had read about anal fissure Bob and his two week recovery and my intense pain made surgery sound like a good option. I was loosing to much quality time in life to this ailment and was ready to try something different to end it. The Surgeon said lets do it and I found out I would have to wait 12 days until surgery and not be allowed to have any Ibuprofen for 7 days before the surgery. It would have been 15 days but I was finally able to convince the nurse that did the scheduling that my pain was in fact much worse than it had been most of the previous 18 months and she moved the day up 3 days (lesson: make sure you know who controls the schedule and make sure they know if you are in bad pain).

Those 7 days were hell. It turns out that the muscles lining the inside of the anus are involuntary. You have a set of voluntary ones that surround the involuntary muscles. That is why you think you have total control over what is going on down there. These involuntary muscles go into spasms that tear the fissure open further. This is what causes most of the pain after a bowel movement (the bowel movement of course has its own driving severe pain). My Ibuprofen usage relaxed these muscles and helped me deal with the day to day pain. Ibuprofen has aspirin in it. Aspirin is a blood thinner and they do not want you to take any aspirin for 7 days before surgery. I found Tylenol (1000 mg) only helped a very little and I was spending three to four hours in the bath tub each day. I started missing work for the first time due to the severe pain caused by my anal fissure. The Surgeon gave me a prescription for Valium to calm the spasms. Valium relaxed the spasms and put me to sleep which was just fine with me. I had told my boss and his boss by this time and they were great and said take as much time off as you need before and after the surgery to get well. I will not be looking for a new boss anytime soon.

What were the surgical procedures?

The procedures were fissurectomy with sphincterotomy. As I understand the first one, the Surgeon cuts away at the fissure to get some fresh meat and then sews it up loosely. Loosely so that the stuff that will eventually get in can get out. The sphincterotomy is a procedure that I do not fully understand but the Surgeon says that he cuts the involuntary muscle that lines the anus and this permanently weakens it so I will avoid having more problems in the future. This sphincterotomy procedure scared me. I read it as the surgeon is going to try and change me from the way I originally was before this fissure and I was not too thrilled about that. I kept wondering what will he break by relaxing these muscles? My Surgeon said "don't worry, if it ends up being too loose, I can go back in and tighten it back up". He also convinced me that the sphincterotomy will relax the anal pressure from an elevated level to a more normal level rather than make it looser than normal. I kept thinking, "if this does not go right, I am in for another round of surgery, I certainly do not want that", but I had talked to three other Drs. about my particular surgeon and the last one said "so he is going to be your surgeon, you do not have to worry, he is really good and will fix your problem for good". This same Dr. also recommended that I try a purely vegetarian diet for a few more months to see if that would help. I had had enough of the diet treatment and my diet was almost vegetarian anyway so it was off to surgery to try and end my pain.

Surgery Day

It took place at the Surgicenter where all they do is outpatient surgery. I rode there with my wife driving. No water, Valium, Tylenol or anything else since midnight. I was in bad pain. They had given me an enema to self administer before going to the Surgicenter. This was the first enema I had ever had so I was not sure how it would go. Enemas are not a big deal. Squirt the fluid in and wait five minutes. Then a trip to the toilet and you are done. So I get checked in at 10:30 AM on a Monday and the nurse comes and says it is my time a few minutes later. I am ready to get this over with but not ready to go at it alone. She says no more wife and then measures my blood pressure at 150 over 90. My high was a good 20 to 30 points higher than normal and the nurse tells me to calm down. She has me take my clothes off, put on a gown, and lay on a table. I was scared to death. The nurse gives up and brings in my wife. This helped, but I loss ground when the Anesthesiologist spends about 5 minutes trying to get a vein up (he finally gave up on my arm and went for my hand) and pokes me at least 3 times and then probes around each time. This hurt but it kept my mind off of the fissure pain. They hook an IV up and then role me in to the surgery room. No wife there. They put me out of my misery a few seconds after they had me slide over onto the surgery table. I was thank full for this. Supposedly the surgery only took about 20 minutes. I do not know for sure.

Post surgery. I wake up and all I want is my wife. The lady says no. So I start asking her for hugs. She gives me a few. It helps and I am thankful for them, but I am still scared. Same story. She gives up and within a few minutes my wife is there. Nothing more soothing than a wife that you love and that loves you. Four hours after I walked in the door to check in, I am going home. I eat some apple sauce and try to sleep. I am taking pain killers, Hydrocodone Bitartrate & Apap 5-500 tablets, every three hours with about 1 cup of apple sauce. Later I learn that apple sauce might be constipating, but this was not a problem for me. I took the pain killers every 3 hours for 24 hours and then took one at six hours and then never took another one. The bottle said "maybe habit forming" so I quit taking anything like that as soon as I can. I don't need any more problems in life.


Surgery was on a Monday so I give up on going back to work that week when I realize how brutal they were with me. I was bruised two to three inches from my anus by what ever they used to hold my anus open to work on it. The Sitz baths help a lot so it is back to spending thirty minutes to an hour in the tub five or six times a day. I read the paper and listen to the radio. By Thursday, I am able to start reading technical papers from work for a few hours each day and actually thinking again. I am beginning to like this. Every time I would have a bowel movement for the first five days, I would get a little drainage and bleeding just as described by the sheet they handed me as we left the Surgicenter. Bowel movements were frightening and painful at first. They would come on suddenly and then I would have to dash in pain to a toilet and take a painful bowel movement. Not the same anal fissure pain, but a new bruised rear end and stitches pain. A good Sitz bath after each movement worked well. They had me rub on Polysporin 2 to 3 times a day on the outside of the anus to help prevent infection. Polysporin is an over the counter antibiotic cream.

I had trouble urinating while sitting on the toilet but I was able to urinate while standing so that is what I did. This was bad the first few days and went mostly away by the first weekend. I could empty 80 to 90% of my bladder by sitting on the toilet. I also found that the set of muscles that stop the urination stream also pulled painfully at the stitches. This was really bad at first and got bearable as the weekend approached. These same muscles also are activated by sudden movements such as trying to sit up too quickly, coughing, or sneezing. Sneezing was really bad. Some of the stitches were visible from outside of the anus. They were thick. Looked like 150 lb. test fishing line. About 2 times the diameter of dental floss. They also poked me which was a minor irritation. Found out at 1 week checkup that they were Vicro #30, probably 1/10 mm in diameter. They look bigger than that.

I never saw the fissure because it was just far enough inside the rear of my anus that I could not see it. I would sit on the side of the bath tub or toilet and look down in a mirror laying on the floor to try and figure out what was causing the pain and to help me put the cream in the correct place. The surgeon had me lay on a table for inspections that put you in the same position that you have while sitting in a chair. I would lay belly down on the table and kneel on the drop out section of the table. In this position he was able to easily view the fissure by spreading my anus open with his fingers. There was a red area to the rear of the anus that looked like my anus had split on the outside. The Surgeon said that was not the fissure and not a problem. It guess not, it was all sewn up after the surgery. There were two things that looked like ¼ inch bags of skin that were on either side of the rear of red area. These would sometimes swell and be sometimes painful. The surgeon called them tags. The tags were still there after surgery but did not cause too much if any pain for the first week. The description in the section II paragraph C of the first medical link in the home page is fairly accurate at describing what I could see.

After Surgery, I stick to the vegetarian diet with a little cheating here and there. The last thing I want is a rock hard stool so I am good with the diet, water, and Metamucil. I eat frosted mini-wheats for breakfast with milk and then fruit, Metamucil, and bean soup for lunch and dinner. I would have a little whole wheat bread sometimes with lunch and dinner too. This works well to keep that stool soft. I had trouble keeping comfortable in bed at night. I found that putting two pillows under my knees and sleeping on my back worked best. I wrote all of the above and the initial home page the first Saturday and Sunday after my surgery. I was able to sit in a chair fine for two to three hours but I was not well. I was also nervous because I was not sure if my progress was good or not. One of my goals of these pages is to provide more information on what people should expect so others are not so nervous as I was.

One week checkup (7 Days Post Surgery)

Yesterday, I was unable to reach down from a standing position (bending at the knees or at the waist) and pick anything up off of the ground without significant pain from what I think was from the stitches and the swollen tags. Today I was able to pick things up with minor pain, this was quite comforting. Sneezing, bowel movements, and the rest were still painful, but not excruciatingly or very painful. Back to my Monday, 12:45 visit. My ride to the Surgeon's office today was a lot more comfortable than my last trip. The Surgeon said the fissure was about 10 mm X 5 mm but he did not typically measure them that way. In short, it was as bad as it has ever been 18 months ago. He said that yes he did remove the red area on the outside in addition to the old tags. What I have been calling a swollen tag is really swollen new skin at the end of the incision used to remove the fissure and bad skin. In previous visits, I did not understand how much skin he was going to remove. I can see now that he told me what he was going to remove several times, but did not explicitly say "I am going to remove the red area and tags too". We just did not communicate. Probably my fault. He said the pain should go away in one more week. I should then be able to urinate 100% while sitting on the toilet. He said that some old guys have so much swelling that they are unable to urinate at all and the Dr's have to do it. He said the stitches should come out by themselves over the next week or two but if not, he will cut them (remove?) at my next appointment in 2 to 3 weeks. He said my swelling was better than he would have expected and the more soaks the better. I attribute the low swelling to the 4 to 6 times daily 10-60 minute soaks (I did a lot of reading in the tub).

9 Days Post Surgery

I am starting to feel human again. The worst is behind me. Pain is still there but not significant.

Three week checkup (21 Days Post Surgery)

I am getting some bleeding from where the stitches are. I dab the area with toilet paper and it looks like I get almost a teaspoon of blood. At my appointment, I realize that this bleeding is from the skin surrounding where the actual stitch exits the skin. The Dr. pulled out several of the stitches. He said the stitches sewed up about a one inch long cut and there were 6 to 8 stitches. It hurt a little when he pulled them out but it was good to get rid of them. For several days, the threads had been hanging out and I would pull at them while wiping after bowel movements. This pulling would hurt and sometime cause them to bleed. I still have a tag like flap (1/4" wide X 3/8" long, 1/8" thick) that is somewhat firm and does not look like it will go away. The Surgeon gave me the impression that there was about a 40% chance it would go away on its own. If not, he will "clip" if off at my next appointment in four weeks.

The Surgeon said I could resume my active sport that day if I wished. I in fact resumed about four days later. My sport does not involve a lot of pounding like jogging, but I do exert a lot of efforts at times. I had a modest sports session with little or no discomfort from the remaining stitches.

I asked the Surgeon about Metamucil and a high fiber diet. He said I could stop the Metamucil if I was getting enough fiber from the rest of my diet. One dose of Metamucil has 3.4 grams of fiber and one apple with skin has 5 grams. I stopped using Metamucil the next day and found no change in bowel movements except reduced volume. I do not think I will use it again unless I have a meal that does not have any fiber in it. I have started eating small servings of red meat once a week or so and having fish two or more times a week with dinner. Occasionally I have chicken too. I usually eat about 1/4 as much read meat as I used to in a meal and 1/2 as much fish or chicken as I used to. I always make sure I get enough fiber with all meals. The US Daily recommended allowance is 30 grams for a 2500 calory diet. If it looks to me like a meal is low in fiber, I have an apple with the meal.

23 Days Post Surgery

A few days after my three week checkup, a thread started hanging out of my anus. It must be from one of the stitches up inside that the Surgeon could not easily get to and remove at the three week checkup. I tried to pull it out myself, but that hurt so I decided to be patient.

27 Days Post Surgery

The thread that was hanging out appears to fallen out entirely. I had been soaking in the tub at least twice a day until a few days ago. I forgot to ask the Surgeon how long to keep soaking at my last appointment. I did not seem to suffer from stopping the soaks. Occasionally the tag bleeds at the base. I suspect I pull it at too hard while wiping and tear it.

6 months Post Surgery

Gone. No pain. It is great to be able to sneeze or cough without any pain at all. Not a single hemorrhoid either. The tag is still there, but it has withered away to the point it is not a problem. This took about six months though.

So did it stay away?

Too early to tell yet. Stay tuned.

So what do you eat now?

I am still skipping milk products except for a few servings per week. I make sure I drink plenty of water and eat a balanced diet. I have resumed eating red meat a few days per week and enjoy fish and chicken the rest of the evenings. I have vegetarian breakfasts and lunches and occasionally a vegetarian dinner. This is working fine.

This is the visit to this page since 27 Jan 97.

Last modified: 13 Jan 97, back to home page.