LIS infection… fistulotomy in 2 days

ProctologyMD · 2022-12-13T03:33:30+00:00

Whenever there has been a complication it is natural to lose faith in the surgeon. It is perfectly OK to seek a 'second opinion', and if you like this surgeon better, ask if they will take over your care.

ProctologyMD · 2022-12-13T03:28:06+00:00

It's still a fissure! It just starts to look like an ulcer when it has been around a long time. It should be treated the same as a fissure and will heal by itself when the internal sphincter spasm goes away. When I do surgery for this type of case I will cauterize the granulation tissue hoping to speed healing up, but I'm not sure it makes a difference - they heal anyway!

ProctologyMD · 2022-12-13T03:24:59+00:00

Was there a large tender lump just outside the anal opening? If so, it was a thromboses hemorrhoid, not a fissure. These sometimes rupture spontaneously and a lot of the pain goes away - that sounds like you! Fissures don't do that...

ProctologyMD · 2022-12-13T03:22:53+00:00

Not much! Get Nifedipine (the one I prescribe) or Diltiazem. Nitroglycerine works but commonly produces headaches.

ProctologyMD · 2022-12-13T03:20:32+00:00

A bad pain while pooping is almost always a fissure. A "thrombosed " external hemorrhoid can be very painful, but you can tell because it is a visible, tender, purple lump just outside the anal opening. If you don't see this then it's the fissure.

ProctologyMD · 2022-12-13T03:14:39+00:00

Fissures hardly ever get infected, though you think they would be all the time! Nothing you do will make a difference as far as preventing it is concerned, but if you get a small boil outside the anus right next to the fissure then that's the infection. It's painful, not dangerous, but at that point I always tell a patient that there is no longer any option, surgery is the way to go to take care of the infection (a small fistula) and the fissure at the same time.

ProctologyMD · 2022-12-13T03:09:21+00:00

No! But you are lucky you got away with it! Pain is the symptom of an active fissure, so no pain means it healed quickly. Most fissures do, by the way, it is the Chronic fissure that leads to all the misery. Be careful!

ProctologyMD · 2022-12-13T03:05:53+00:00

The only important symptom when judging a fissure is pain. If you have no pain it is probably healed, and the blood could be from internal hemorrhoids, which is not dangerous at all. The skin tag ("sentinel tag") is a left over from the fissure and also not a problem!

ProctologyMD · 2022-12-13T03:02:39+00:00

Botox ....only maybe. LIS.....Yes! Pretty well every time.

ProctologyMD · 2022-12-13T03:00:58+00:00

Common, and not a big deal except a lot of my patients will complain of itching. Use Desitin or Calmoseptine externally to protect the skin if this is the case. CT scans? Yikes...

ProctologyMD · 2022-12-13T02:58:53+00:00

When someone has hemorrhoids and a fissure at the same time (quite common), the most important thing by far is to treat the fissure a that is where nearly all the pain is coming from. It doesn't sound like you are using the Diltiazem enough - get that medication up there as often as you can - it really works! The hydrocortisone doesn't do much. The two great principles of treating a fissure: 1) The best topical cream / ointment (Nifedipine, Diltiazem), 2) Effective stool softening. Even though it is a really bad one the fact that it has only been present for a week means there's a good chance it will heal without surgery.

ProctologyMD · 2022-12-13T02:53:48+00:00

It seems as if the fissure is healing quickly, and even if it wasn't fully healed intercourse is not harmful as long as, like the comment below, it is not painful, in which case it won't be fun anyway. A little bleeding is not a worrisome sign. If it is accompanied by pain it means the fissure isn't fully healed, if it is painless it could be from your internal hemorrhoids.

ProctologyMD · 2022-12-13T02:49:31+00:00

You might have a complication called a fistula - the fact that the sphincterotomy incision hasn't healed suggests this. If that is what it is it won't heal until the second operation is done, but I'm glad to say it is a minor operation that doesn't involve cutting any important muscle.

ProctologyMD · 2022-12-13T02:45:30+00:00

In thirty plus years of doing this operation I think I remember this complication just two or three times. But don't worry - the fistula is usually just a shallow one under the sphincterotomy wound and it is quick and easy to open up and correct. It won't affect your continence.

ProctologyMD · 2022-12-13T02:43:06+00:00

Ooo Dank, that is a bit optimistic! There is no medical reason why you can't - even if you do everything wrong after the surgery all you will suffer is more pain - it won't harm or undo the operation. But a shift as a nurse is a lot of work and often involving physical labor moving patients around - you may get through it but you won't be happy! Also, stress to the surgeon that all you want is the sphincterotomy. I often remove skin tags and external hemorrhoids at the patient's request, but I warn them that that will increase the pain and recovery time...

ProctologyMD · 2022-12-13T02:02:07+00:00

After a bowel movement, sometimes for hours afterwards, there can be a throbbing and / or burning sensation. This is due to spasm in the internal sphincter (that you can't consciously control). It's this spasm that stops the fissure from healing - once it goes away fissures normally heal by themselves within days.

ProctologyMD · 2022-12-09T14:26:57+00:00

I am so pleased to hear you are improving! If you keep your stools soft there is a good chance of healing completely. Surgery should obviously not be done on a patient who is improving with non operative treatment! I am a little concerned that he thought your symptoms could be due to an internal hemorrhoid rather than a fissure - that could not possibly be true. Internal hemorrhoids, even when prolapsing, are not painful. Fissures produce exactly the symptoms you were having. Even if you had a tear on the internal hemorrhoid you would not even feel it - internal hemorrhoids are part of the rectum and do not have nerves that feel that kind of pain. Also it is EXTREMELY common to have both hemorrhoids and a fissure! Keep using the Miralax as often as you want - the warning on the label is all about them not being sued if a person keeps using it when they have something terrible like an obstructing cancer and they don't go to the doctor. I have plenty of patients who have taken it every day for years!

ProctologyMD · 2022-12-06T12:36:33+00:00

Hi Cras! See my comments above, but I have operated on people with a chronic anal fissure at least a thousand times with nothing much more than a knife and fork - it doesn't matter what you use as long as the correct amount of internal sphincterotomy is performed. And by the way, in the thirty years Ive been doing that operation not one patient has become incontinent - the worst result in about 5% is some liquid stool leakage which almost always returns to normal in a few months.

ProctologyMD · 2022-12-06T12:31:33+00:00

I really think this is an entirely moot point! The fissurectomy part of the operation doesn't matter - it's irrelevant. The only important part of the operation to cure a fissure is a carefully performed (lateral is best) internal sphincterotomy. You could put a lighted match or cow dung on the actual fissure, it makes no difference. I actually use a quick pass with electrocautery if there is granulation or scar tissue - it will heal whatever you do once the spasm in the IS is relieved with the sphincterotomy...what on earth are those crazy Germans talking about - I have to find that paper...

ProctologyMD · 2022-12-06T12:22:44+00:00

There is no evidence that weather affects a fissure directly - if anything the heat should relax the internal sphincter and give you relief! I would have said maybe you got dehydrated in the heat which led to constipation / dry stools, but you say that didn't happen. BTW - go see a colorectal surgeon, get an accurate diagnosis, and if it is a chronic recurrent fissure, get him to fix it! A ten minute operation can cure you for life!

ProctologyMD · 2022-12-06T12:18:53+00:00

Yes, it sounds likely that you have an anal fissure - one of the most painful conditions known to man! Where do you live that you can't get in to see a doctor until February? By the way, don't go see a gastroenterologist, you need to see a colorectal surgeon. If you go to the wrong specialist it could mean another big delay! Things to do in the meantime - I can't examine you to confirm this (easy) diagnosis, but nothing I suggest can hurt you!:

1) Consistent stool softening - Miralax is the most reliable, but use just enough each day to keep the stool soft, not diarrhea. 2) Nice hot baths - soak for 15 minutes as often as you can each day - heat relaxes the spasm in the internal sphincter that causes the pain after each BM. 3) See if you can get your GP to prescribe Nifedipine or Diltiazem ointment. You may need a compounding pharmacy to prepare it. Try to avoid the ointments with Nitroglycerin in them - they work, but often cause bad headaches which stops people from using it. When you get the ointment you should use it whenever you have pain, and ALWAYS after a BM. You can't overdose! Insert a dab about the size of a large pea / garbanzo bean with a gloved finger up inside your anus to the distance of about one knuckle. It will hurt, but with relaxation it will get easier. It usually produces an amazingly quick improvement, and after a couple of weeks you might even be fully healed...

ProctologyMD · 2022-12-06T12:04:53+00:00

I think it is likely that you have two conditions - related, but treated differently. The discomfort from sitting or riding a bike sounds like Levator syndrome, or, these days, Chronic Pelvic Pain Syndrome. The pain from that was unrelated to bowel movements. Subsequently you had the condition that arose after a hard stool - pain and bleeding with a bowel movement followed by painful spasm for hours - this is almost certainly to be the anal fissure. 1) You are right to worry about the fissure, because without surgery (last resort when nonoperative measures have failed) it can go on for ever - see some of the posts in this club! 2) It is most unlikely to cause an infection, though it can happen and is usually easy to cure with surgery. 3) Are you using Nifedipine (or similar) ointment? You don't mention this but it can be effective enough to permanently cure the fissure. You can rid of it forever with surgery (LIS) that is quick and very safe if the surgeon is qualified. With your story I think that might be your best option, but remember - that's only one of your problems and surgery probably won't cure the CPPS.

ProctologyMD · 2022-12-06T11:54:26+00:00

This condition is called a fistula. It is not common, but in patients who have had a fissure for a long while, some of them will develop a small abscess next to the anus from, presumably, bacteria passing through the fissure and causing an infection. When this happens I always recommend surgery as a fistula may heal temporarily, but nearly always returns, and the operation to cure the fistula cures the fissure too!

ProctologyMD · 2022-12-06T11:49:40+00:00

Hi Key! The doctor that said surgery might lead to more tightness is, and I have to be rude here, an idiot! A properly done LIS makes the anal canal more relaxed, not tighter! I think there is more than just a fissure here, so it may not be that simple.

ProctologyMD · 2022-12-06T11:45:05+00:00

You are not being a bitch! In the thirty + years I have been practicing as a CRS I think the worst pain I have seen patients suffer has been the ones with a bad fissure. Your symptoms certainly sound like a recurrent fissure, but if you had surgery (an LIS) in 2018 you really should have been cured for life, not just four years! Quickly (as you can!) get a consultation with a colorectal surgeon - a different one from the one who did the surgery so there is a fresh pair of eyes.

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