Patient 8

Patient 8

Date: Tue, 3 Mar 1997 Original Submission
Date: Tue, 18 Mar 1997 Update
Date: Mon, 14 Apr 1997 Update

Subject: Progress report
Date: Mon, 3 Mar 1997 21:42:19 -0800

Don't miss the updates!


I wrote to you recently telling you about my recurrent anal fissure. You asked me to write back with updates, so here it goes.

First off, I went into my surgeon prepared with literature that I downloaded from the web regarding nitroglycerin (NTG) treatment. He was impressed and made the comment to the attending intern, "You see what is going to happen? You are going to get smart kids like this who come in here knowing more about their affliction than we do!" He was very interested in where I got my information, considering he has been using NTG for only a few months. Of, course I informed him of your page and once again I thank you.

I was given 0.5% NTG to be used 0.5-1 hour before a bowel movement by applying a dab of the cream around the very outside of my anus. However, I wanted to make sure that I was doing everything properly, so I contacted Dr. Gorfine at Sinai medical in NY via E-mail. Dr. Gorfine told me that he found more success with applying the cream three times a day in addition to both before and after a bowel movement AND to apply it within the anal canal as opposed to the exterior. Apparently, external application can induce headaches more easily than if applied internally. He also informed me that hydrocortizone suppositories have never been shown to work effectively in curing an anal fissure; a method I used to recover from my previous encounter with this demon. I do feel that this may be the truth, as time seemed to heal my wound more than anything. Finally, Dr. Gorfine recommended that I not sit on a foam donut because it tends to inflame the fissure. Basically, anything that stretches the anus can cause discomfort as I have found out. However, the donut often times does seem to help, while at other times it seems any position hurts.

Thus far, I have been on the NTG treatment (using Dr. Gorfine's guidelines) for about 3 full weeks. In that time, I have noticed a gradual decrease in the daily pain and discomfort. Unfortunately, today was a particularly hard day for me as I started it off with a rather burdensome bowel movement. The pain I feel today is at the level I started and, of course, I feel a strong sense of disappointment and anger. Looking back on yesterday's meals and activities, the only thing that I can point to is that I had lots of chicken and an oh-so-good hot fudge sundae with my usual onslaught of vegetables, fruit, water, stool softeners, high fiber cereal, ibuprofen, and docusate sodium (a stool softener). I am wondering whether the chicken/milk caused me to have a big dump to put it frankly. I am definitely going to lay off meats and dairy products as your pages suggest. The other thing that I did differently was to exercise on a sit down machine (Health Rider) and I also helped a family member move heavy furniture the day before. I bring these up because my condition has of late worsened and I am unsure why! I have asked a plethora of proctologists/surgeons if both hard physical exercise or specific types of food can promote or initiate a tear (via a bowel movement). In all cases, the response was that they can only increase the discomfort level of an anal fissure, but cannot promote it or create it in any way. So, not trying to avoid specific foods, I went on eating as usual and came up against problems only this morning.

This brings up a point that I would like to make in regard to my experience with anal fissures: Once you get one, plan on being in pain for the next month or so (depending on the severity of course) but do not plan on having a clear understanding of what is best for you to do. As I say, sometimes certain sitting positions seem to relieve strain, while the same positions seem to cause discomfort the next day. Some days I will bleed a lot (say 1/4 cup) when I take a dump, while other days I will have no sign of blood ... and for me, there is no link between the pain I feel and the blood level ! What is a constant is time. Time heals all wounds, yes, but you may go through hell to get there. I feel at my stage that Satan will make me a manager right away in lieu of the private hell I have already gone through.

Not to be discouraging. I am feeling better by the day. But the process is slow. My concern is really in regard to my future. Okay, so I get cured and beat this thing again..then what? One day in the future I decide to have some ice cream to top off my steak dinner and bam, 3 more months of hell? I don't think so. My plan is to risk the incontince I may suffer in getting a lateral sphincterotomy if I get a second recurrence or if the current plan fails. Dr. Gorfine has NEVER (to his knowledge) rendered anyone permanently incontinent after such a surgery, although he does claim to have a lower cure rate of 90% as opposed to that reported in the literature ranging from 95%-98%. Surgery should never be the first option. I have, however, been dealing with my fissure intermittently for the last 2 years. I have paid my dues. In addition, perhaps the surgery will also enable me to heal if problems arise from future meat and dairy based meals..who knows. I do know that there is at most a 10% chance of becoming permanently incontinent, while the rate of recurrence after both NTG and surgical treatments also falls around 10%. BUT, these statistics do vary widely. According to Dr. Bender (The Butt Doctor on the web) a properly performed sphincterotomy should not render someone incontinent. Dr. Gorfine is one who has achieved this, my only concern is how my surgeon's record is!

There is something to be said concerning the mental toll as well. I read some of the accounts on your pages and sympathized with all. I recently had to vacate my seat at a restaurant where my girlfriend and her parents (on a visit from New York) were dining. What do you say!? Do you just say, "Ah..I have to go to the restroom, excuse me .." and then come back 20 minutes later? Sticking with my honest personality I confessed my dilemma to the parents and excused myself for a walk around the block. Perhaps I felt more embarrassed than I should, but suffice it to say that socially, I have had to curtail or end many activities I normally attend. Last week, my girlfriend and I had to dash out of an opera just as the warning bell was ringing because I could not see how I was going to make it through a 3 1/2 hour performance while I writhed in pain all the while. My girlfriend was very understanding, but the sense of loss in not being able to do the things that make you feel happy: see a movie, lift weights, hot fudge sundae, etc, all have to be put aside for what has seemed like an eternity. Even sex can hurt as having an orgasm inevitably results in you squeezing your butt muscles and if your have a fissure, it may result in some discomfort. The list goes on and on. As the days progress, my tension grows and I am trying to not let it get the best of me. I have always been a fighter, now I am working on my endurance I suppose. In any event, if anyone out there feels as I do concerning these issues, your are obviously not alone! Sometimes a burden, if known to be shared, can lessen your grief if only psychologically. Your home pages have given me this hope and sense of shared experience, which has been a great mental inspiration for me!

I will keep you posted of further progress. The statistics for healing with NTG are on my side, so hopefully I will prevail! I would like to add one final warning concerning one of the things I was doing to help treat my anal fissure: DO NOT USE MINERAL OIL! I was told by my surgeon to drink a tablespoon or so of mineral oil every other day to help lubricate the stools and to work as an effective laxative. According to Dr. Gorfine, however, there are numerous adverse complications that can occur in using mineral oil. I will personally attest to this! During the first week of NTG treatment, I would try to time the application of the cream so that approximately one hour later, I would have a bowel movement. But when you gotta go, you gotta go and one day I tried to hold out just a little bit to let the NTG take effect before going to the bathroom. Most embarrassingly, I became a little incontinent as a result. Keep in mind that I was not straining very just slipped out! I attribute this to the mineral oil as Dr. Gorfine also surmised. Since, then I have not ingested any mineral oil and have had no similar experiences. The benefits do not outweigh the negatives in using mineral oil.

Date: Tue, 18 Mar 1997

Enclosed are a few self contained web pages which may be helpful. Let me know if you wnat anything else added or if they would be of value to you. I believe it may help some people..BTW,I am scheduled for a lateral sphincterotomy next Tuesday, but I will tell you what my final decision was and how things went when I cross that bridge.

Thanks, Patient 8

His pages are two nice tables that describe some primary care methods and does and donts.

Subject: Patient 8 Post Op Update
Date: Mon, 14 Apr 1997

Hello Jack! I am writing to you in lieu of my recent lateral shincterotomy surgery. I wanted to let you know of my condition and progress.

The report is very simple: no pain, no pain, no pain! After about 2 1/2 weeks I felt absolutely no discomfort during or after a bowel movement. In addition, and much to my relief, I am experiencing no incontinence to gas or liquid whatsoever.

My decision to have surgery was mainly based on the idea that I would get a future recurrence of the fissure. I was on 0.5% NTG and it seemed to be working, but I must say that it wasn't working fast enough for me. I had already missed about two months of steady work as I was forced to work at home and after being on the NTG for approximately 10 weeks, I still was in moderate to severe pain. Keep in mind that I was sticking to an extremely strict regimen (See Patient 8, Regimen I, II). So while I felt that eventually NTG and time would would eventually heal the fissure, I was convinced that I would get it again and have to start all over. Based on the level of pain and debility I had endured, the thought of another recurrence was unacceptable. I wanted my life back!

Armed with the information I found on your page, I began asking my physician and other surgeons around the country questions concerning lateral sphincterotomies and anal fissures in general. I was surprised to find a fairly large variance in opinion regarding both the root cause of anal fissures and risks of surgery. While all agreed that relaxing the spasmodic sphincter muscle was a curative measure, there was a difference of opinion regarding the root of the anal fissure problem. Some surgeons feel that anal fissures are caused by insufficent blood supply, primarily induced by the increase in intra-anal sphincter (IAS) pressure via the spasmodic action of the sphincter muscles. In addition, one surgeon asserted that the typical location of fissures (the 6 o'clock position) receives relatively less blood flow than other areas in the region, and thus contributes to the problem. Another source may stem from the hypothesis that many people who get fissures have an elevated resting IAS pressure, which tends to worsen any condition that may befall them. My surgeon stated that there is absolutely no reason to believe these ideas, as "certainly, there is plenty of blood supply in that area." His assessment was that once you get a fissure, an involuntarily spasmodic sphincter muscle was the main culprit and that the NTG works because it releases nitric oxide, which calms the muscle. Once calmed, the IAS pressure drops as well as inflammation, giving the fissure a chance to heal. A major concern was the risk of incontinence. First off, the muscle that is cut in a lateral sphincterotmy helps you distinguish between gas and liquid in the anal canal. Thus, cutting it may lessen your ability to differentiate, and you may accidentally pass some liquid instead of gas. This condition may be PERMANENT. Ever heard of the phrase "nothing is forever"? Guess again. However, you DO NOT lose control of your bowels as the primary sphincter muscles are left in tact. So, risk of incontinence does not suggest that you are going to be wearing Depends all your life; rather it suggests leakage in liquid/gas form. Some surgeons cut the spasmodic muscle only partially, decreasing your risk of incontinence to gas. However, this comes at the cost of decreasing the success of the surgery. Now the scary part: statistics for incontinence to gas/liquid range from about 4% - 30% following a full lateral sphincterotomy. My surgeon was the one who quoted a recent report out of the University of Minnesota which claimed a risk as high as 30%. Not good. Typical observations suggest about 10%-12%. To his knowledge, however, my surgeon has never rendered anyone incontinent. I was in so much discomfort and pain, I decided to accept the risk, especially in light of his expertise and success as a surgeon. The surgeon I saw is considered to be one of the best surgeons in the Pacific Northwest, and patients visit him from all over the world. He has performed literally thousands of colorectal surgeries in his career and works in a medical center that is considered by many to be the best primary care facility in the United States, while excelling in many specialty areas. The point is, be careful and picky with your surgeon and the establishment in which he works. Go to someone you have confidence in and ask many-a-probing question concerning their expertise. I straight out asked my surgeon, "Are you good? ...because I don't want you to screw me up for life and I need to trust you before I ever step foot into that operating room." He was very open and appreciated my honesty. Good sign.

I was not given a spinal or an epidural that I was aware of, but I was knocked out via an IV during the surgery. It lasted aproximately 40 minutes total. That is, once I entered the surgery room, I left about 40 minutes later. I believe that once prepped, the surgery takes only about 15 minutes. I felt so damned good after my surgery that I was amazed. I was given Percocet (pain reliever) and docusate sodium capsules (stool softeners) and was told to stick the regimen I had been following for the last couple of months (minus the NTG cream). The Percocet, while working to relieve the pain and making you want to hug your worst enemy, also constipates you. (If there is one common theme in having an anal fissure, it would have to be irony! You need to shit everyday so that your stools remain soft, but it hurts like hell when you do. You need to take pain killers after surgery, but they constipate you. Certain exercises that help to keep you happy and in shape only serve to irritate the fissure due to an increase in abdominal pressure, which apparently results in increases IAS pressure, et cetera, et cetera). Suffice it to say that I had the largest bowel movement of my life two days after surgery and boy was I sweating it. It did hurt very much and I bled a little, but compared to what I had endured, I believe it to be only slightly worse. I was sure to maintain a steady flow of blood in my Percocet drug stream to relieve the pain. The next day I again had a large bowel movement which in itself would have been a record had it not been for the previous day's encounter. However, day after day slipped by and I found myslef feeling less and less pain. That is until I pulled my back out and dropped to my knees from the pain. This is altogether a different story but I may warn others that the back of neck was very sore after the surgery because of the position I was put in (feet over the head). I have strong stomach muscles and am in pretty good shape, and am always careful with my back. However, I believe that all those days on the couch resting on my side may have contributed to my back being a little out of shape and out of whack. One reach for a broom with a slight twist of the back and I was down. I literally couldn't walk for a 3 days without assistance. Major bummer. Anyway, if you have a bad back and elect to have this surgery, you may request the face down position. Anyway, beyond the back condition, I was feeling great. The relief of being able to sit down was enormous! My god, I don't have to worry about going to a movie, or to an opera, or a ball game, or riding a bike, or anything anymore! I simply cannot express the relief I feel.

My 2 week post-op check up went well and the doc said I was healing wonderfully. My only hope is that I never ever get this again. Yeah, I know, nothing is forever. But I have taken a step to drastically reduce the odds of ever getting or dealing with this thing again. According to Dr. G. out of Sinai Medical in NY, the recurrence rate after a lateral sphincterotomy is only about 1.2%. So, the odds are with me. I am going to adopt a new diet for a while (basically cutting out a lot of meats and dairy products), but this is mainly because red meat always makes me feel a little queasy anyway no matter how much I crave it!

My thanks for all of you who contributed before me. I cannot tell you how comforting it was to hear your stories and in some cases, recieve support via E-mail (You know who you are!). My hope is that I can now help others out there who are too embarrassed or unfamiliar with anal fissures to approach a physician. Believe me, there are many people from many walks of life, that have this condition...and I know how much pain one can go through. So you aren't alone! If anything ever comes up in the future, I will be sure to write. But, no offense, I hope I never have to write to the self help page again!

Ciao and good luck!
Patient 8.

This is the visit to this page since 04 March 97.
Last modified: 16 April 97, back to
home page.