Introduction Section One : Description of an anal fissure
Chapter 1. What is an anal fissure?
Chapter 3. How do I know if I have an anal fissure?
Chapter 4. What is the difference between an anal fissure
Chapter 5. Typical medical advice and procedures
Section Two: Things that have worked for me
Chapter 6. In General
Conclusion Other Sources Introduction I have written this book in the hope that it may help others who suffer from the painful condition of living with an anal fissure. For some people the condition is a lingering one which they are seldom free of, while for others it may only last a few weeks. Either way, the pain can be excruciating. My own fissure has been my constant, unwelcome companion for quite some time – I decided against the surgical route – and I have learnt various ways of alleviating the pain, reducing the discomfort and living a normal life in
spite of it. I hope that I can share with you these methods, which have worked for me. I had a lengthy period of trial and error before finding what would work and what wouldn’t. I would be happy if I could spare others that trial and error period.
What I am offering here is not medical advice and it is not a substitute for medical advice. If you have, or suspect you have an anal fissure, your first port of call is your doctor. The first part of this little book stresses that. It tells you what an anal fissure is, how you can identify it, what will happen when you first visit a doctor with the problem and what action he is likely to take. This is information which you can get elsewhere on the internet. I have simply summarized it in fairly simple terms.
The second and longer part of the book gives you, in detail, all the things that I do which have helped. They add up to what looks like a formidable list, but they quickly become routine. I hope, very much, that they will also assist others in coping with an anal fissure and managing, to some extent, to beat it.
SECTION ONE Anal Fissures Chapter 1: What is an anal fissure? An anal fissure is a small tear or ulcer in the lining of the anal canal, the short passage between the rectum, where your stools (the poo) is stored and the anus – the opening in the backside that the poo comes out through. The anal canal is only between one and two inches long but in cases where the stools, the poo, is either very large or very hard, the anal canal is subjected to considerable pressure and a split can be caused in the wall of the canal. This is an anal fissure.
Anal fissures are usually classed as “primary”, where there is no obvious cause for the fissure or “secondary, where the fissure has been caused by another illness or condition. They can also be classed as “acute anal fissures” which normally heal themselves and only last for about six weeks. Others of us have to learn to live with them – we have “chronic anal fissures”.
Whichever kind you have, the symptoms are the same – you feel acute pain not only when you are passing the stools but for a considerable time after your bowel movement. The secondary pain, the pain after the bowel movement, is a deep burning sensation which is not restricted to the anus but makes the whole lower body feel very uncomfortable.
Chapter 2: Causes of anal fissures
Some anal fissures are the direct result of other conditions and are known as secondary fissures. This applies in particular to people who already suffer from any form of
inflammatory bowel disease, such as ulcerative colitis or Crohn’s disease. The swelling, or inflammation, of the tissues can lead to ulcers forming on the wall of the anus.
Secondary fissures can also occur as a direct result of pregnancy. There is an increased risk of developing a fissure during the last two months of the pregnancy, when most women find it harder to pass stools without straining. A tear in the anus can also be caused by the straining of muscles during childbirth itself.
Where there is no other condition that might lead to a fissure developing, an initial tear can be caused by straining to pass a really unusually hard and large stool. In most of these cases, you will probably know that you have done it, or at least be able later to identify exactly when it happened. A tear caused in this way should heal by itself in a few days and you may be able to prevent another fissure by taking action to stop yourself ever becoming so badly bunged up again. Once you have had a fissure, you will be desperate to avoid constipation in case it causes another one!
However, it is not always caused just by constipation. In many cases the fissure is due to a problem with the ring of muscle, the sphincter muscle, which is round the anal canal. If this muscle is too large, it exerts too much pressure on the canal, partially closing the canal, cutting off the blood supply to it and making the walls more fragile and more likely to develop tears. This is the most likely cause of repeated or chronic anal fissures in people who have no other bowel condition. In these cases, anal fissures are likely to be an ongoing problem.
Chapter 3: How do I know if I have an anal fissure?
It’s the pain. If pooing feels like passing broken glass – yes, as excruciating as that – then the chances are that you have an anal fissure. In many cases there is bright red blood on the toilet paper or in the loo itself. The excruciating pain as you pass the stool is then often followed by several hours of a deep, burning pain up the backside. This is clear evidence that you have developed an anal fissure. At this point, you need to make an appointment to see a doctor so that you can have the fissure examined and get some medication and advice. Chapter 4: What is the difference between an anal fissure and a hemorrhoid?
Hemorrhoids, also known as piles, are another cause of bleeding from the backside when passing stools. They can also be painful, but not to anything like the same extent as an anal fissure. It’s the difference between pain that makes you say “ouch” and pain that makes you cry. Hemorrhoids are the “ouch” variety and anal fissures are definitely the crying variety.
A hemorrhoid is a swelling on the blood vessels around the rectum and anus, usually caused by increased pressure on the vessels through straining when constipated. If there are several of these swellings the passage of the poo through them causes discomfort. You will normally also get evidence of blood on the toilet paper and severe itching round the anus. This itching is one of the most marked symptoms of hemorrhoids.
Most hemorrhoids are internal, being inside the anus and round the edge of the rectum, but some people get external hemorrhoids just at the outer edge of the anus itself which can be felt as small swellings. Hemorrhoids will normally reduce and disappear by themselves although in a few cases they may need medical treatment.
The symptoms of hemorrhoids are easily controlled by lotions or gels which you can get over the counter and apply externally to the anus. Obviously, if you have evidence of blood when passing stools, even if you believe it is simply because of hemorrhoids, you should always consult a doctor.
An anal fissure, on the other hand, is an actual tear in the tissue surrounding the anus. It is much more painful and requires medical treatment.
Chapter 5: Typical Medical Advice and Procedures.
As I said in the introduction, this book is not in any way a substitute for getting medical treatment. If you think you may have an anal fissure, you need to get medical advice and help.
Your doctor will need to examine your anus. He will do this by gently parting your buttocks. In most cases that will be enough for him to see the fissure. (Don’t try doing this yourself with mirrors – it’s seriously difficult and rather off-putting!) If he can’t see the fissure, he will need to press gently on the edge of the anus, and you are likely to experience pain when he does this. It will hurt – so Yell Out Loud – this is no time for being brave and it lets him know that there is a fissure even before he can see it.
In a few very rare cases he may need to do a rectal examination. This means doing an internal examination, either by inserting a gloved and lubricated finger up the anal canal or by inserting a short lighted tube to find out if there are any abnormalities. These and other forms of rectal examination are likely to cause acute pain and you should discuss this with him first. It is possible to have a rectal examination performed under a local anesthetic.
Typically, you will be given advice on preventing constipation by changing to a high fiber diet, taking exercise and increasing your water consumption. You will be advised to take painkillers to control the pain. At this first appointment, the doctor’s aim is to promote healing of the fissure naturally without any medication. ou will be given another appointment in a week or two so that he can see whether the fissure is healing by itself.
In cases where at the next appointment the fissure shows little signs of healing quickly and naturally, you may be prescribed medication that will relax the sphincter muscle to take the pressure off the wall of the anal canal. Typically this medication will be Nitroglycerin to expand the blood vessels round the canal, making the walls less fragile.
Nitroglycerin is usually applied as an ointment to the anus for six to eight weeks or until the fissure has healed.
Nitroglycerin can have side-effects, sometimes severe, causing headaches and dizziness. An alternative to the use of Nitroglycerin is the use of Calcium Channel Blockers, either taken as a pill or applied as an ointment to the anus. This is a medication which is normally used for people with high blood pressure. In the case of someone with an anal fissure, it is used because it relaxes the sphincter muscle, reducing the stress and tension round the anus. Again, there are side-effects, headaches, flushing, or dizziness. Some brands of oral blockers can actually cause constipation.
If you are prescribed either of these, you should discuss the likely side-effects with your doctor before taking them so that you will know what to expect.
The other medication which you may be prescribed is an injection of Botox (Botulinum toxin) which temporarily paralyses the sphincter muscle, giving the fissure time to heal. This is sometimes used if other medications have not proved effective or if the patient doesn’t want to take them because of the side-effects. Botox is a powerful poison, but used in minute doses it prevents the sphincter muscle from going into spasms and contracting when you are trying to pass a stool. It reduces the pain and allows the fissure time to heal.
None of these medications are likely to be prescribed as a long-term solution. They are all intended to help the fissure to heal quickly.
In order to try to alleviate the pain when you need to poo, some doctors may prescribe a topical anesthetic, usually a Lidocaine gel or ointment such as Xylocaine which you can smear onto the anus before passing a stool. Disposable latex sheaths for your index finger are provided with the gel and you simply try to apply the gel round the inside of the anus. These anesthetics have to be used with care as they contain toxins, poisons which, if they enter the blood stream, can cause serious side-effects.
If a fissure does not heal in about six weeks, you will probably be referred to a specialist, either a proctologist or a gastro-enterologist. You can ask to see a specialist if the doctor has not suggested it himself. A specialist will almost certainly carry out a full internal examination of your rectum, but this should be done under a local anesthetic and should not cause you any discomfort.
In cases of a primary fissure where it appears that other methods of treating the fissure are not working, he may recommend that you have surgery, either to remove a section of the sphincter or to cut out the fissure itself. The second option seems to be less well thought of among medical professionals because it doesn’t treat the underlying cause of the fissure and so the fissure is likely to recur. The first option, removing part of the sphincter, is considered successful in the majority of cases, but some people are left with what they call “bowel incontinence”.
Section Two Things that have worked for me Chapter 6: In General
As I said in the introduction, I decided against having surgery for my acute anal fissure. Medical professionals will mostly only want to use surgery as a last resort and I thought it would be better to see how I got along without. Quite apart from the possibility of permanent “bowel incontinence”, I felt I should measure up the possibilities of other complications that could occur during the surgical procedure. This is a personal decision which each of us has to make for himself. I can only say that, a year later, I feel I made the correct decision.
I have made several lifestyle changes, in my eating habits and in the amount of exercise I take. I have found ways of managing the pain and discomfort caused by the fissure and of considerably reducing it. I feel a great deal better than I did a year ago. I reckon it is possible to beat this condition without having invasive surgery. It’s certainly well worth a try!
The most important state to avoid is being constipated. If you have an anal fissure, it is vital to develop regular bowel habits and have soft stools that will not cause any further damage. Much of what follows is concerned with the diet you should follow and the training of your bowels to prevent constipation. But I have also found a number of methods of pain management and, perhaps most importantly, several things that will make things much less painful.
Chapter 7: Diet
Some authorities believe that the majority of people who suffer from bowel complaints, hemorrhoids or anal fissures have always had a degree of constipation without realizing that this isn’t normal. Your stools, your poos, should be reasonably firm, but never hard, and you should not have to strain in order to pass them. With a fissure, you need to have stools that are softer than normal without being runny. You need to be able to pass soft poo without any straining and you can only achieve that with a higher fiber diet than you’re used to. A high fiber diet means eating more fruit and vegetables and more whole wheat and whole grain foods. It means eating less meat, less white bread or white rice.
The ideal diet should contain between 25 and 30 grams of fiber daily. The average diet in the USA contains between 5 and 8 grams. To keep the bowels moving regularly and not forming hard, painful lumps of poo, I certainly found that having regular meals helped - three meals a day, none of them too big, always at much the same time each day. Try to include fruit, green leafy vegetables, brassicas (cauliflower, broccoli etc.), well-cooked beans, yogurt, wholemeal bread and high fiber cereals. Yogurt doesn’t have fiber but it helps the gut to produce helpful bacteria that break down the waste and lubricate it.
A really high fiber day’s menu might be:
Breakfast: a small bowl of Bran Buds (10 grams of fibre) or Bran Flakes with raisins (5 grams of fibre) with yogurt or milk(no fibre) and a banana sliced on top (3 grams of fibre). A glass of fresh orange juice with the bits in (1½ grams of fibre)
Lunch: A large plate of salad or a large salad sandwich in a wholemeal baguette, rocket, tomato, cucumber, raw cabbage (1-2 grams of fiber)
Dinner: Half a cup of baked beans in sauce or cooked dried pinto or black beans (8 grams), three or four spears of broccoli (5 grams) a couple of slices of chicken (no fibre).
But it isn’t that easy to change overnight and it certainly isn’t easy to reach the 30 gram mark every day. I use a patented fiber substitute, Benefiber, which I sprinkle on a drink last thing at night. Benefiber has worked well for me. Added to water it makes an orange tasting drink which is not at all unpleasant. There are plenty of other fiber supplements like this if Benefiber doesn’t suit you. A daily tablespoonful of Psyllium seeds, Hydrocil, or Citrucel sprinkled on a drink is a painless and easy way of getting plenty of fiber. A tablespoon of any of these patented fiber substitutes can add an estimated 15 grams to your fiber intake.
If you are going to try to change your eating habits, you need to know which foods have plenty of fiber. The following table gives you some items from a helpful and much more detailed list g(Note: sometimes this site won’t come up. Gclick on Centers and Departments; click health conditions on the left side and then on bowel function. The second page here gives you the full table of foods containing fiber, with details of how many calories and how much fiber each food type contains. If you are trying seriously to achieve a balanced high fiber diet, this is one of the best sites I have found.
Table 1: Dietary Fiber Content Food Type
Cooked Greens. Eg kale, Swiss chard ½ cup
Dried White Beans, canned or cooked 1 cup
This could be a starting point for trying to change your diet – it’s better not to try to change dramatically because the gut might over-react and cause diarrhea, which doesn’t help. You might start by having a slice of 7-seed or rye bread instead of that white bagel for breakfast, eat an apple at lunchtime, have some frozen broccoli with dinner. The last British government were widely ridiculed for creating a “nanny-state” where they tried to change people’s lifestyles and eating habits – really in an effort to reduce pressure on their overloaded national health service. One of their ideas, however, was snapped up by supermarkets as a marketing strategy. “Five-A-Day” has become an everyday phrase and every child can tell you that they should be eating five portions of fruit and vegetables every day. It’s given a great boost to sales of those fiber-rich foods in the UK. I only tell this because it might be helpful to think in a “five-a-day” mode. An apple, some broccoli, fresh or frozen peas, an orange, and a bowl of rocket gives you the “five-a-day” requirement, provides a fairly fibrous diet and would be a good start towards beating constipation. I found it helpful to note down daily how much fiber I thought I was
getting. It began by falling a long way short of the required 30 grams and that helped me to make an effort to eat more fruit, vegetables, wholewheat products, brown rice, beans and so on. On a final note in this chapter, beans are full of fiber and eating them in moderation as part of your normal diet is probably the best possible way of staying regular and of not causing any further strain on the anus. Try a night out in an Italian restaurant that serves bean soup and you’ll see what I mean. In fact changing from meat protein to the protein contained in pulses, beans, dried peas, lentils, would be an excellent way of taking the strain off the walls of the anus caused by poos that are too hard. If you are going to cook dried beans, soak them for 24 hours first, changing the water twice, before boiling them gently until they are soft. Beans are notorious for creating a lot of wind – there must be a hundred old jokes about horses who have been fed on beans – but if you change the soaking water, the enzyme that causes this is removed and wind shouldn’t be a problem. Chapter 8:Fluids Still on the same topic of trying to make sure that you never again have to strain to get a really hard poo out, it’s essential to take lots of fluids. The gut and the bowel need a lot of liquid to keep the poo soft. This doesn’t mean increasing your intake of tea, coffee or beer and other alcohol, because they are all diuretics – they make you pee. So instead of the liquid getting into the bowel and rectum to soften up your poo, it just comes out as pee. I have found that drinking a lot of water is very helpful, ideally several glasses a day, but certainly a glass or two of water with every meal. If you can’t give up your coffee, have a glass of water with it. Having soup, especially a lentil soup or a vegetable soup, for one of your meals is another way of both increasing your fluid intake and increasing your fiber intake. Fresh orange juice for breakfast is another drink that can help to prevent those hard, painful stools. If you can juice it yourself, it’s even better because it will have some of the fibrous bits in it. Chapter 9: Bathing I find it very helpful to soak in a warm bath with some Epsom salts added every night before going to bed. I think what this does is to relax the whole area round the anus and help it to heal. The warmth relaxes the muscles and there is less tension and stress. It is certainly very soothing. The use of a Sitz bath several times a day is recommended by a large number of health care professionals. The Sitz bath is a plastic tub that fits over the loo seat so that you are actually able to immerse your backside in it. You fill this tub with warm water and soak in it for about 15 to 20 minutes. You can add more warm water as it cools since the bath
overflows into the toilet. Again, if you are able to do this, it is very comforting and helps in the healing process. You are advised not to add anything like bubble bath or scented bath salts to the water. I haven’t explored any of the herbal additives since I have had such good results from using Epsom salts, but there may well be possibilities there. One of the main problems in having an anal fissure is that the area round the anus, between the buttocks, is one of the prime sweaty parts of the body. It is very difficult to keep it dry and the dampness, combined with the salt in the sweat, is one of the main reasons that anal fissures can be so difficult to heal. That, I think, is the real point of using a Sitz bath several times a day. It cleans the area of all the body salts, you then pat it dry with a soft towel. Putting on some talcum powder after the Sitz bath can be helpful, but it must be pure talc, without any sort of scent in it. If your pharmacist can’t get you pure talc, baby talc is probably the next best thing. Soaking in warm water is definitely useful for relaxing the area round the anus. Keeping the anus clean definitely makes it much more comfortable and as well as soaking for the sake of the soothing effect, I have also found that it is much better to wash my butt in warm water after having a poo. One of the problems in America is that we just use toilet paper to clean ourselves after we’ve had a poo. In Europe, they use toilet paper first and then wash themselves in a bidet. These are like wash-basins on ground level, with hot and cold taps. You sit on it and turn on the taps and you can then wash your bottom properly, using your hand and the running water. Using toilet paper after you have pooed when you have a fissure is extremely painful. I find it much better to wash the butt properly in order to clean the anus and the area around it. You can wear a disposable latex glove for this if you find it too disgusting. Some people with fissures clean themselves in the sitz bath after their bowel movement. This is fine, but obviously you have to empty the bath after the intial cleaning, fill it again with clean water and rinse yourself with the clean water. In a bidet you can have the plug in or out, you can clean yourself with warm running water or you can fill the bidet and just let the painful area soak for a bit. If you have a chronic fissure that won’t heal or keeps recurring, it might be worth exploring the possibility of getting a bidet fitted – they are available in a few places and I think they would be better than the sitz bath for cleaning. As I said before, keeping the anus clean with toilet paper is simply not helpful if you have an anal fissure. Wiping yourself with paper cannot clean the area around the fissure properly because, quite simply, it would be far too difficult as well as being far too painful.
I have found that you really need to be able to wash your backside gently in warm water after having a poo and then dap it dry with a soft towel. This isn’t always possible if you need to pass a stool when you are not at home (but see Chapter 11 on training the bowels not to have to move at difficult times!) so it is helpful to always carry some super-soft toilet paper in case you are not able to wash. Another good thing to have when you are out is a packet of the little damp wipes that are used for babies. You can use these to gently clean around the anus and between the buttocks to keep the area as dry and clean as possible. Make sure that the wipes you buy are not scented, which they shouldn’t be for a baby’s skin. And if you feel it’s a bit prissy to be using baby wipes – they are what the guys in the military in Afghanistan use fofr wiping the dust off their faces in combat! Chapter 10: Medicines This is a short chapter because I am not in any way trying to stand in as a medical professional. Anyone with an anal fissure needs help, advice and prescriptions for medicines from a doctor. I am simply letting you know what I have found has worked for me. I have in the past on a few occasions used a topical anesthetic to deaden the pain when passing a stool. This can be especially useful in the early stages although applying it can in itself be really quite painful. Doctors will be unhappy about topical anesthetics being used on a regular basis and they certainly will not recommend their use for more than a week at a time. They contain steroids but the real problem is that they contain a strong toxin, a poison, that can have some fairly awful side-effects, so no-one should use them for more than a few days at any one time. If you are going to use them, it is certainly better to keep them for times when you know beforehand that trying to poo is going to be very painful. This can, of course, make things worse. If you have anesthetized the anus, you are likely to strain hard because the pain is not so bad and the straining may open the fissure up. It’s better to try to make things easier, firstly by your high-fiber diet and also by using a laxative. I take a laxative most evenings, well before the time when I expect to pass a stool (see Chapter 11). I use Senna Lax which works well for me in softening the poo and has no other side effects. It is also incredibly cheap. I buy 200 pills, which last me for a long time, for something in the region of $10. If you prefer, you can buy the Senna pods (they grow on a bush) and make a hot laxative drink by pouring boiling water on them – adding a spoonful of honey makes it quite palatable. Again, this is very cheap, completely natural, and works well. I normally take a painkiller if a poo has been unusually painful or if I can sense it’s going to be painful afterwards. I find that taking two Aleve works well. Aleve doesn’t contain steroids and is an anti-inflammatory drug. I think any anti-inflammatory painkillers will
work well because they reduce the swelling round the unhealed fissure and therefore there is less tension and pressure. Chapter 11: When to go and How to go I have found it very helpful to train the bowels to move just before I go to bed. That way, I can have a relaxing bath with Epsom salts afterwards, can take a couple of painkillers if I need them and can then sleep through any ensuing pain. I think most people have a poo, when things are normal, in the morning. It’s just a matter of trying to move that later and later. Timing when you take a laxative can help in changing the time when you poo. I also found that if I went and sat on the loo for a bit in the later evening, the bowels got the idea and began to contract and move then. It really is important not to strain. If the poo isn’t coming and there is a lot of pressure, try to consciously relax the butt muscles. Slump a bit on the seat and consciously think about the muscles in the backside, letting them relax. (This isn’t as difficult as it sounds – you can practice it with arm or leg muscles.) Sitting on the seat and reading a paper or a book, taking time over it, even using a sitx bath to warm and relax the area when you’re under a lot of pressure but nothing is coming out can all help. Straining and pushing will damage the walls of the anal canal even further and cause more pain. I also find that it makes things much worse if I don’t have a poo every day. When you first have a fissure, passing a stool is so painful that it’s a temptation to try to avoid passing them. Getting more and more constipated only makes things worse, I’m afraid. I have found that it is far better to try to make sure the poos are soft and move the bowels regularly. At the same time, you want to avoid overdoing the laxatives to the point where you have diarrhea. Diarrhea might sound like a good solution; it means no hard, painful poos. But it doesn’t work like that because the constant bowel movements that are involved in having diarrhea cause irritation to the lining of the anal canal and make the fissure worse. It’s also very difficult to keep the fissure clean and free from poo if you are constantly going. Chapter 12: Exercise This is all part of the lifestyle change that is necessary if you are going to beat the anal fissure without having to resort to surgery. In addition to a healthier diet with increased amounts of fruit and vegetables, you will need to take a certain amount of exercise in order to keep your bowels moving. It is estimated that the high volume of laxative sales in the US is dependent on the sedentary lifestyle of most of its citizens.
This doesn’t, I am glad to say, mean that any of us have to become fanatics who work out at the gym for two hours every day. It simply means a moderate amount of exercise to get the system moving. Walking instead of taking the car for short distances, having what the English call “a constitutional” – a walk round the park or round the streets every evening - is probably enough. If you feel like jogging, or playing tennis or golf, that’s great, but even a small amount of exercise will help the system to overcome the problem of constipation. One thing about exercise, however, is that even the mildest amount can make you more sweaty. If you are undertaking fairly vigorous exercise, make sure you are able to have a bath or a shower afterwards, or even just a sitz bath so that you can wash around the anus and between the buttocks and get the area a clean and dry. Even if you are just going for a good walk, try to clean the anal area, with a baby-wipe if you can’t actually wash it. Swimming can be very beneficial because the muscles you use aren’t putting any strain on the base of the spine and the buttocks. You need to make sure you can have a shower in non-chlorinated water afterwards. The same with sea swimming, if you can do it. Salt water swimming can be very beneficial but make sure you have rinsed off all the salt afterwards. Conclusion I have tried, in this little booklet, to give you information which I hope will be helpful in learning how to manage your anal fissure. I have described the things that I have found have worked for me. I have lived with this painful condition for a bit over a year and I can honestly say that things have improved and I am much more comfortable and in less pain than I was a year ago. Achieving this more comfortable condition has meant changing my diet. I eat more fruit and vegetables and more whole wheat products than I used to. I drink considerably more water and believe that this has been vital. I also take more exercise than I used to, consciously taking the decision to walk whenever I can, to climb up stairs instead of using the elevator, to do a few gentle exercises every day. In addition to a higher fiber diet, drinking more water and exercising, I use a fiber supplement added to a drink, usually take a gentle and natural laxative product daily, use an anti-inflammatory painkiller when I need to, and have managed to change my bowel habits so that the bowels move regularly, every day, and usually at night when I can then handle any subsequent pain more easily through sleep. I have adopted the habit of not using toilet paper but instead washing the anus and surrounding area with warm water after a poo. I use Epsom salts in a warm bath to relax the muscles, to soothe the painful area and to promote healing.
As a result of all these changes I have become less constipated and my bowel movements cause me far less pain than they used to. They are also causing far less damage to the anal canal and this is enabling the fissure to heal. Fissures can heal, but they can also come back again. Much of what I have described here can be summed up as a complete lifestyle change which you need to continue with even if the fissure heals. The high fiber diet and the use of fiber substitutes are not a short-term solution for anyone who is liable to get anal fissures. It means maintaining this routine to avoid it happening again. Other Sources
There is plenty of information from health professionals about anal fissures on the internet. I have found some sites more helpful than others and have listed below a selection of the ones that I have found most helpful. Boardsailor describes the experience of other sufferers, one of whom went down the surgical route. Some of the others are sites of medical professional giving very detailed descriptions of the condition and of the other bowel conditions that can cause a secondary fissure.
CYMBALTA® (DULOXETINE) ABBREVIATED PRESCRIBING should not take this medicine. Interactions Caution is advised when taken in INFORMATION Presentation Hard gastro-resistant capsules, 30mg or 60mg of combination with other centrally acting medicinal products or substances, duloxetine. Also contains sucrose. Uses Treatment of major depressive disorder. including alcohol and sedat
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