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Medicine & Other Modalities

Like other unwanted life events, a fissure can require time you’d rather not give, energy you’d rather not spend, decisions you’d rather not make, and actions you’d rather not take. But if it doesn’t mend soon (within about six to eight weeks of onset), a fissure can become much harder to treat, so quick attention is advantageous. Thankfully, when you do choose to seek care, competent and compassionate people make it their business to fix fissures, and proven products, procedures, and other styles of therapy (or “modalities”) have been developed to help you heal.

Still, choosing repair options can be challenging. Trips to the drug store may seem awkward. Medical exams may feel uncomfortable and reveal occult (hidden) issues or yield bad news that you’d rather not know. Treatment might affect nearby parts or influence other important functions. And since some options carry small but possible risks to continence, rapid relief might spawn a new burden.

Nonetheless, I found that not taking enough of the right kind of action at the right time can be costly. So in this section, I’m going to share a few principles and personal experiences that can help you move toward resolution. I’ll start with an overview to prepare your mind for action, briefly describe several treatment options with a few comments based on personal experience, and then share my own results.

Taking Action

Get no worse. A powerful way to start solving instead of suffering is to set your current condition as your lowest repair point. This means that everything you do from now on should maintain or improve your situation. Some things are beyond personal control, of course, and setting a baseline doesn’t ensure that things won’t go lower. But putting in a floor provides motivation, momentum, and a clear path up.

Is it a fissure? It might seem obvious, but the best way to fix a fissure is to make sure that a fissure is really what needs fixing.

The anorectal area contains a remarkable array of features, and with each feature comes the potential for trouble. The anal canal itself is the site of many possible problems, such as a fissure, abscess, fistula, hemorrhoids (technically, “hemorrhoidal inflammation disease”), anal warts, or cancer. Some conditions share the same symptoms, and others involve the same tissues. For example, both fissures and cancers affect the squamous (flat) epithelial (outer surface) cells of the anal mucosa (moist and slippery skin). So when it’s time to get on with repair, a medical examination by a qualified professional is the best way—by far—to determine the true nature of your current condition.

Define success. As a product designer, I’ve found that project teams often overlook the important step of defining success. So what does “fixed,” “repaired,” or “healed” actually mean? There are subjective and objective answers to this question.

Since a healthy anal canal must continue to expel waste under conditions created by many life choices, you might define success by first taking some subjective measurements. Sample questions you might ask yourself: Am I hoping for the identical function and geometry I had pre-fissure? Am I willing to make diet, exercise, or lifestyle adjustments to allow the body’s natural healing mechanisms to fully do their job? Am I willing to accept some trade-offs for quicker relief? Am I ready to try products or techniques that will help me heal? Answers to these and similar questions can help you establish your own clear definition of success.

On the objective side, it might help to distinguish successful fissure management from successful fissure resolution. Why is that?

From a management perspective, your body is probably already doing a fabulous job. Consider the following, which is my usability analysis as an interactive product designer:

From an interactive design perspective, then, a chronic fissure could hardly be managed better. The fact that it takes on a stubborn protective form over time is a feature, not a flaw, and could mean that a contributing issue hasn’t yet been fully handled.

So you see the idea: if you respond to the body’s automatic management by keeping stools bulky but very soft, if you don’t use damaging muscle movements that force fresh granulation tissue apart, if you don’t further abrade (scrape or wear away) granulation tissue by passing hard stools or during clean-up, if you keep the sphincters’ nearby neighbors calm and relaxed, if you don’t impose extra tension by deliberately clenching, if you avoid diet and lifestyle items that might cause irritation and inflammation, if you don’t over- or under-react to sensations of pain, and if you do everything else you can to keep healing blood supply high, then it logically follows that you will heal. You are cooperating with the body’s natural management process to reach resolution.

But sometimes healing doesn’t happen, despite your best efforts: technique may be off, little or no new granulation tissue gets produced, or other factors may be in play. So to achieve resolution, a more active response may be necessary. The next few principles can help.

Prepare. Because fixing a fissure can sometimes feel like a high-stakes proposition, I found that it’s helpful to mentally prepare before and while you engage with the healthcare community. I’ve alluded to this in previous sections, but it’s worth emphasizing since doing so can yield at least four benefits:

The first benefit is balance. As a designer, I’ve observed that the prevailing feelings of a project team can dramatically affect the product development process, and if negative emotions take hold, great results may become hard to visualize even if they’re relatively easy to achieve. So to keep gloom at bay, it makes sense to invest a little time building and maintaining a balanced view of possible medical outcomes. For example, while it’s possible that you won’t gain quite the same level of function as before, it’s also possible that you’ll actually surpass your former level and get even better, since you’ll now be equipped with more knowledge, hindsight, foresight, insight, and—if you choose to make one—a protocol that can lead to future success.

The second benefit is shared understanding. Engaging with the healthcare community can feel a little like getting tech support for your computer. A good support engineer likely knows more about the functional and technical details of your system than you do, but you know more about your history, particular use patterns, and overall experience. I learned that crafting a match—where you and your healthcare provider consciously try to converge on the best option for you—is easier if you prepare your thoughts than if you just show up and see what happens. I know this is true from personal experience, as you’ll see shortly.

The third benefit is readiness. Like any discipline or community, what first seems to be rock-solid medical information can in practice be open to interpretation, difference, and professional debate. If you’re trying to reach an informed decision, a regular flow of new or conflicting data can feel confusing. Readiness simply means that you spend a few minutes preparing yourself to absorb new information and quickly use it—or not—to shape your definition of success.

The fourth benefit is confidence. Preparing to make a decision or take an action before you actually have to make or take it gives you time to evaluate options and get comfortable with your eventual choice. This is especially helpful if you face a surgical decision.

Engage. If you have resolved to get no worse, have taken a few moments to define success, and have prepared yourself to absorb, choose, and act, then the next step is to engage with helpful people and products. I’ll go into more detail about this step in Treatment Options and My Results, which are coming up shortly.

Review and calibrate, or keep the change. Once you’ve chosen a course of treatment, it’s helpful to customize that course to your own circumstances. Resolving a fissure may mean multiple doctor’s visits and trying different treatment types, but between those events, you’re in the best position to help yourself heal. Keeping your repair process close in mind, rather than pushing it away, can help you actively review your results to date. You can then calibrate your course as needed, keep the changes you’ve already made, or do a little of both. Since a protocol invites you to stay engaged, I found that such thoughtful and deliberate action can help you work within your chosen treatment to achieve its best results for you in the shortest time.

Treatment Options

Previous sections covered some diet and lifestyle ideas to help you heal, but other options may be needed or desired. Here are some possibilities, along with a few observations based on personal experience:

Over-the-counter Options

If you’re not familiar with the term, “over-the-counter” (or OTC) simply refers to medicinal products that are available without needing a doctor’s prescription.

Colace. This is a brand name for docusate sodium. Colace acts primarily as a stool softener and does not induce bowel movement like other laxatives. At my doctor’s recommendation and a few weeks after I had undergone a surgical procedure, I started taking one small, easy-to-swallow capsule a day. Along with better eating habits to ensure optimal softening, it worked great. In retrospect, I should have started using Colace earlier.

Laxative tea. Some herbal tea blends include a stimulant laxative, and since they may come with specific directions or warnings, I’m including them here instead of in the Eating & Drinking section. I tried laxative tea once or twice before switching to Colace, and I found it to be tasty and effective. Other than the natural power of prunes, I had little prior experience with digestive assistance products, so natural laxative tea provided a gentle introduction. If needed, I’ll happily use it again.

Pain-relieving and/or protective liquids, gels, creams, and ointments. Before going to the doctor, I attempted self-care with several different options, including some classic remedies like aloe and witch hazel. While some provided minor relief, none really addressed the problem, and a few made things worse. My suggestion based on experience: if you find yourself trying to lessen pain with topical remedies and you haven’t seen a doctor yet, make an appointment soon. If you’re still determined to seek an OTC option, consider one that contains lidocaine or its brand-name versions (such as xylocaine), which are used in prescription solutions.

Pain relievers (acetaminophen, aspirin, ibuprofen, etc.). I tend not to take any kind of medication unless absolutely necessary, so when I do take something, the minimum dose usually works well. That said, ibuprofen seemed to produce best results among the options I tried. A note for fellow medicine-avoiders: I probably would have done better easing off my “only-when-absolutely-necessary” rule; following it did not deliver any measurable short- or long-term benefits, whereas modest use of OTC pain relievers definitely helped.

Fleet enema. My familiarity with enemas was limited to television shows that depicted large hanging bags of solution flowing through long surgical tubing. Fortunately, modern products are far simpler: the liquid solution is pre-mixed in a small squeezable bottle that comes with a ready-to-use flexible delivery tube. An enema may be required before any anorectal surgical procedure, and might also be used to flush out hardened stool, though I can’t speak to that from personal experience. What I can say is that you should heed the package directions about duration of effect (approximately six hours) since the solution can continue to produce prodigious and fast-acting results during that entire time. And, as with other medications that affect the natural digestive process, make sure to pay attention to all directions and cautions and consult a qualified medical professional if you have questions.

Prescription Options

Most medical references explain that the first line of treatment for non-chronic fissures involves diet and lifestyle changes, along with warm baths to relax the sphincters. The next line of treatment (and maybe the first for chronic fissures) is prescription medication. Some high blood pressure medications taken orally may help relax sphincter tension, but I have no direct experience so I can’t comment on effectiveness. My experience with prescription medication is limited to topical solutions.

Nifedipine or Nitroglycerin ointment. This topical solution combines a base, such as petroleum jelly, with a small amount of lidocaine or similar pain reliever, and a small amount of nitroglycerin (also called glyceryl trinitrate) or nifedipine (or a similar calcium channel blocker, such as diltiazem). Without going into the chemistry, the key ingredients diffuse into the skin and produce a localized relaxing effect. While both nifedipine and nitroglycerin can also produce unwanted results, such as a drop in blood pressure, flushed face, or headaches, the side effects are lower with nifedipine, and that’s what I was prescribed. The only side effect I experienced was a single incident of slight facial flushing.

If you get a prescription, the ointment will probably need to be made at a compounding pharmacy, which is a specialized pharmacy set up to produce mix-to-order medications. The official directions told me to apply a “1/2 pea-sized” amount near (but not directly on) the affected area a few times a day. Since my international diet has demonstrated that peas can vary considerably in size, my suggestion is to start small but ramp up quickly to larger amounts; if you feel light-headed, dizzy, or flushed a few minutes after application, use a fraction less the next time—you may have found your sweet spot without side effects.

In my experience, the ointment tended to separate and get runny when exposed to high temperatures or during hot weather. Since the carrier substance may be petroleum-based, any amount that contacts clothing can permeate fabrics and can be difficult to remove with water. So while you want to achieve maximum effectiveness, be aware that using a larger amount might get a bit messy. A liner or barrier of some sort between the ointment and clothing can help you use an effective amount without stressing over staining.

I was hoping that the nifedipine would work, and I even tried a second course before moving on to other options (this was before I developed my personal protocol). But it was not to be, and in fact, professional medical literature puts effectiveness rates around 70%. Still, since prescription ointments contain lidocaine and help with relaxation, I believe I would have been better off starting with a prescription rather than experimenting with so many OTC options first.

Post-surgical prescriptions. If you undergo one or more surgical options, as I did, you might also be given prescription medications for use while healing. I was issued two prescriptions: Docusate, a stool softener, which I ended up accidentally not retrieving from the pharmacy and thus never using, and Vicodin, a pain medication, which I ended up choosing not to use since it can cause constipation. Instead, I simply used over-the-counter ibuprofen for pain and natural foods as a stool softener, though later I would start taking Colace. A suggestion: if possible, try out any OTC medicines before surgery so you can see how your body responds. I didn’t do this, and everything worked fine, but I would have had greater peace of mind had I taken a test drive.

Surgical Options

Before discussing surgical options, I should mention that creating a personal protocol may help the body resolve a fissure on its own, but it’s not a replacement for professional surgical assistance when needed. In my case, I found the two approaches to be complementary, since learning to properly relax anorectal and pelvic floor muscles is as valid after surgery as it is before. The advantage of starting a protocol prior to surgery is that you can practice, experiment, and make a few mistakes without undoing any surgical help. But a personal protocol should never be used to validate procrastination.

Many fissure surgeries are outpatient procedures, meaning that they don’t include an overnight hospital stay. If you choose to move forward with a surgical option, the procedure might be performed in a doctor’s office, at a hospital, or at a surgery center, which is a specialized facility designed to make the process effective and efficient. In my case, the procedure was performed at a surgery center, and I found the experience to be quick, thorough, and professional. As a practical heads-up, some surgical services (such as anesthesia) were performed by separate business units, so I was billed by more than one entity.

Here are some possible surgical options, described in non-technical terms:

Exam under general anesthesia. Though a chronic fissure may be partially visible externally, its true length, width, depth, and other attributes might only be discovered by a more thorough exam. Since the sphincters are pulled tight in protective mode, a complete exam may need to be done under general anesthesia, which is a surgical procedure. If you’ve ever achieved the pleasant euphoria of a “runner’s high” through exercise, the initial effect of general anesthesia may feel similar, though faster and foggier. After losing consciousness, you likely won’t notice anything else until you wake up in a recovery area. Before you can leave, you’ll need to have someone present who will make sure you get home safely.

During the exam, your doctor may use a series of tools (such as anal retractors or an anoscope) to get a detailed view of your particular situation, and—if your doctor is anything like mine—will take immediate steps to help remedy the fissure. This may include fissurectomy, chemical (or pharmacological) sphincterotomy, lateral internal sphincterotomy, or similar steps.

Fissurectomy. Any kind of -ectomy means that something’s coming out, which for fissures can be a little confusing: if a fissure is already a cut, how can you cut it out? A fissurectomy is like a reset—it removes the scarred, indurated (hardened) superficial skin surrounding the split, possibly including the sentinel tag and hypertrophied anal papilla, which encourages the production of new granulation tissue. The freshened edges of the fissure might then be sutured together with a single long piece of surgical thread, which will give the granulation tissue a good chance to connect and create a successful scar.

Botulinum toxin injection (BTX). Frequently described as a chemical or pharmacological sphincterotomy, injections of botulinum toxin—often known as Botox or Dysport—temporarily cause denervation (loss of nerve supply), which produces a “paralyzing” effect that relaxes the internal anal sphincter. The effect lasts for up to three months, and the combined therapy of fissurectomy and BTX injection can result in healing rates (depending on which reference you consult) of up to 93%. My medical insurance covered BTX injections, so at my doctor’s recommendation, which we discussed prior to surgery, I went forward with that option in combination with fissurectomy. I’ll provide details shortly.

Lateral Internal Sphincterotomy (LIS). LIS is considered to be the gold standard of surgical fissure repair. In this procedure, a surgeon cuts through the internal anal sphincter muscle laterally (off to the right, left, or both sides of the fissure) to mechanically lower tension, somewhat like unbuttoning a tight pair of pants. There are two basic styles of LIS: open and closed. In both styles, the surgeon finds the intersphincteric groove by palpation (feeling with the fingertips). In the open style, a small (about 0.5 cm), smile-shaped incision is made over the intersphincteric groove, which, with a little work, provides a clear (or “open”) view of the white fibers of the internal anal sphincter. Using scissors, the surgeon then snips the internal sphincter, up to the same length as the fissure. In the closed (or “blind”) style, the surgeon inserts a blade into the intersphincteric groove and slides it upward, parallel to the internal anal sphincter. Once it travels the appropriate distance, the surgeon rotates the blade and cuts through internal sphincter muscle. Either style releases tension, allowing the body to heal itself.

The actual LIS procedure doesn’t take long—usually less than 20 minutes—and as most medical references point out, has a very high success rate with relatively low incidence of complication or mild incontinence. The initial recovery period is similar, or maybe shorter, than for fissurectomy plus BTX.

Other Surgical Options. Digital anal sphincter dilation (or dilatation, sometimes called anal stretch) is a method of manually dilating (widening) the anal canal, which has effect of tearing and thus loosening muscle fibers in the internal and external sphincters. Based on higher rates of complications, including incontinence, this procedure is considered obsolete, though more controlled techniques appear to be in the experimentation stage at the time of writing.

Another option is dermal flap (or anal advancement flap), which uses a healthy flap of skin to cover the fissure. Though often reserved for patients who meet specific criteria, some medical publications seem to suggest positive results for a larger population.

Of course, if you are even remotely considering surgery, your best course of action is to meet directly with a qualified medical professional for an expert description of any surgical procedure.

Other Treatment Possibilities

Though not a typical solution for fissure repair, I found physical therapy (PT) to be extremely useful. My course of treatment focused on pelvic floor therapy, so that’s what I’ll describe here:

Pelvic floor therapy. Based on my desire to learn muscle relaxation, my doctor prescribed a course of six sessions of pelvic floor therapy, each about an hour long. The sessions were conducted by the same physical therapist and were spread out over several weeks, which gave me a chance to implement what I learned and then discuss results.

The PT setting and atmosphere were more casual than a clinic, almost like a private gym, but my physical therapist and therapy sessions were highly professional. A private exam room included several helpful items: anatomical charts and models, sample therapeutic products that I did not know existed, and an electromyography (EMG) machine for biofeedback.

The sessions provided time to explore causes of pelvic tension that I had never heard about, and probably never would have thought to think about, such as pelvic congestion syndrome (or a similar male version), pelvic floor dyssynergia, and paradoxical contractions. Though none of these conditions seemed to be a contributing factor, I appreciated the thoroughness, and I found that going through a fuller investigation led me to take a more active and knowledgeable role in my own repair.

Additionally, though my primary interest was the real-time EMG feedback, my physical therapist introduced a number of discussions, tools, and techniques that also helped. A few of the physical exams and diagnostic questions were quite…forthright, but ultimately useful. Suggested diet, exercise, and lifestyle changes provided good ideas and motivation. And while the specific relaxation techniques I tried didn’t fully address my goal, they did point clearly to the need for deliberate muscular control. That clarity, in turn, fueled my determination to see low EMG feedback numbers consistently.

And that’s what I attained. Between sessions I tried various gentle changes to the pelvic floor, much like the small but effective adjustments you might make to achieve good posture or to work more ergonomically. Then, at each session, the EMG feedback told me exactly what I needed to know: which muscular states provided optimal levels of relaxation. Once I locked those states into my memory, I found that I was able to achieve a greater level of pelvic floor relaxation more or less on demand. Even now, I can achieve the same or similar state at practically any time. So in my case, I consider physical therapy for fissure repair to be a stellar success.

My Results

If you’re considering surgical options, I offer my experience as a case study, as it may prompt some thinking that can help you save time and make any procedure an even greater success:

(Content describing this part of my experience is available for purchase in other formats. I discuss my personal immediate, short-term, medium-term, and long-term results, and I offer a few insights and suggestions for persons who have consulted or will soon consult a qualified medical professional.)

Since the overall process took longer than the quick and definitive LIS procedure, you might wonder why I didn’t just start with LIS, or proceed immediately to LIS after my first attempt with BTX didn’t take.

I saw three main paths to muscular relaxation: structural, chemical, and personal. Since fissures can recur, I reserved the structural path as a final option. The chemical path—both the nifedipine ointment and the BTX injections—yielded some key insights, so I chose to try the personal path as my next step. For my definition of success, that worked best—the fastest route to success was the one that taught me muscle relaxation for the long term.

But it did take time. And though my definition of success might be different from yours, time is likely as large a factor in your decision-making process as it was in mine. So it’s time to talk about Time.

Last updated: June 2019