A 38-year-old female with a past medical history of constipation and hemorrhoids presented to our office with anal pain and bright red blood on toilet paper. The patient states that she has severe pain every time she has a bowel movement. The pain lasts for about an hour. On a scale of 1-10 she rates her pain a 9. Nothingalleviates the pain; it only goes away with time. This is also the first time she experienced pain like this. She states that she noticed blood on the toilet paper in the past but just attributed it to hemorrhoids which she was diagnosed with in the past, during her pregnancy.
On the digital rectal exam, the patient had internal hemorrhoids as well as an anal fissure
Anal fissures are small tears or cracks in the anus that are sometimes mistaken for hemorrhoids, which are swollen blood vessels either inside or just outside the anus. Both conditions often arise from the passage of hard stools.
Causes:
Fissures occur when the anal mucosa is stretched beyond its normal limits, typically due to constipation and hard stools. Once a fissure forms, it leads to repeated trauma. The exposed internal sphincter muscle beneath the tear goes into spasm, causing severe pain. This spasm also pulls the edges of the fissure apart, hindering the healing process. Additionally, the spasm can cause further tearing of the mucosa during bowel movements.
Treatment:
For the anal fissure, the patient was prescribed stool softeners and a compound cream which contains three medications: a numbing agent like lidocaine, an anti-inflammatory medication like hydrocortisone, and a medication to relax the anal sphincter to help with the healing process. The patient was also counselled on keeping a high fiber diet and taking a warm water bath for 20 minutes about 3 times a day to help relax the anal sphincter
The patient returned for follow up after 6 weeks and wasfeeling much better. She stated that the pain had gone away and she did not notice any more blood on the toilet paper.
For the internal hemorrhoid, we offered the patient a hemorrhoid banding procedure called hemorrhoid banding. This procedure is non-surgical and painless. It involves placing rubber bands on the three blood vessels that give blood to the hemorrhoids. This procedure was done in 3sessions (one for each blood vessel).
We had also scheduled this patient for a colonoscopy, since she never had one done and we wanted to rule out other problems such as inflammatory bowel disease and colon cancer which can cause symptoms similar to those of anal fissures.
