so i have this problem with my butt.

things to never, ever type into a google image search

no pictures, please. no, really.
i have an anal fissure. some traumas are more glamorous than others. begging off of a saturday night with friends because you broke your ankle on the black diamond last week is one end of the spectrum. "sooorry guys, i gotta stay in, my aaaanal fisssure is acting up" would be the other end of that spectrum. and that's where i am- the other end. frankly this is an embarrassing illness, at least at first. you're sniggering at yourself, with your going on about ass-pain all the time. snigger, you say, about my butt! chortle. gee, you joke, someone really lit a fire under my....

after a while though, you stop making jokes. this is because you can't access the language centers of your brain anymore, which have been converted along with everything else into additional pain centers.

i've become something of a connoisseur of pain in my time. it's been kidney stones, kidney infections, GERD, IBS, catheters of various stripes, a cone biopsy of the cervix without any anesthetic, childbirth without drugs, and two years of backfiled taxes- i feel as though i qualify as something of an amateur expert on the subject. if there was a job which only required sitting in a room and hurting i feel i would be eminently qualified to do so. it's not my kink or anything, i just know how to endure buttloads of senseless pain. let me assure you, anal fissures hurt like hell. you aren't a wimp, it's not in your head, other people aren't living with this all the time far more gracefully than you ever could. this shit hurts.

a quick word about squick

if you're here because you're my friend, or you think i'm funny, or just because it's a little sunday websurfing, i would be remiss if i didn't remind you that this is a page about anal fissures. it's here to provide plain- spoken tips to sufferers on how to feel better with a viciously painful disorder of the butt. that means it's going to get to things to do with your ass you probably can die happily never hearing about. proceed with appropriate caution.

what causes it?

in short: constipation and being a bit, uh, tightassed. trying to get a hard stool though a small opening, something's gotta give. sometimes, that's you. this is your ticket to a veritable carnival of pain. after the first little tear, every time you go to the bathroom you are now trying to do it with an open wound. any hardness, any tightness, means that tear will easily get bigger. sometimes it's a skin tear, sometimes the muscle beneath gets torn. it gets a few hours to heal, but pretty soon it's time to work again, and tear again. With that kind of delight to look forward to many people start holding back; this leads to the end level boss of anal fissures because the longer you retain a stool the more water your body sucks out of it, the more it's going to feel like a bouquet of razorblades coming out.

getting an anal fissure is not a freudian thing, it doesn't mean you rebelled against your parents by practicing anal retention and practice makes perfect. there's a good chance you need more fiber. if you have an anal fissure, the atkins diet may simply not be for you. i suspect i had a proto-fissure brewing for a while, but childbirth traumatized the area and very very hard stools post- childbirth ripped me a new one. many people look back and see their diet wasn't all it could have been. others discover that lactose intolerance or other food intolerances are the hardness culprit. every once in a while you're just kind of built that way, and laxatives may need to be a way of life for you. if your sphincter just likes to spasm and tighten all the time, the only thing that may work for you is surgery to cut the sphincter. both of these are extremes, but they happen, and when they happen, they aren't anyone's fault.

it's also pretty common to be constipated after giving birth. partly it's the lovely hormone jig, partly because the nerve that tells your rectum, and consequently you, to expel its contents can get a bit damaged. again, the longer material stays in your rectum the dryer and harder it gets. this is why it's important to go often, go early. that can be hard to do once you have the anal fissure- consciously or not, the anticipated pain can make it very hard to work up the willingness to do your business.

getting better

there are two things you have to do you get better:
1. achieve very soft stools
2. totally relax the sphincter while having a bm

a combination of medications, diet, relaxation and even surgery can help you manage these two things. but even when you do manage them, getting better can take a while. you have to heal up down there, and that can seem like it takes forever. be patient, and look for little gains.

the medications come in two varieties: things you swallow and things you stick up your butt.

things you swallow

*stool softeners - things like colace (otc) and miralax (prescription) help introduce water to the bowel and help you pass stools more quickly. some of them are ok to take forever and some of them should only be taken for short periods of time. check with your doc, and if you're feeling paranoid, cross-reference what the doc tells you with a pharmacist. what you don't want to do is take things that give you diarrhea. you think you want diarrhea, and you're dead wrong. what you don't need right now is to go to the bathroom every few minutes. really, diarrhea makes the baby jesus cry when the baby jesus gets an anal fissure.

this brings me to a side point: there's a very good chance the baby jesus did have an anal fissure. most children get fissures when they make food type transitions, because they often get terribly hard stools while their digestive systems adjust to the new form of food. for this reason, potty training while making a food type transition can be hell for a little one. there may be nothing you as a parent can do for your suffering child except be thankful infant amnesia means they won't remember it. i've had mineral oil suggested, but this is a controversial solution, and one i don't feel qualified to weigh in on. what a lovely segue that makes to mineral oil.

*intestinal lubricants - the idea is to slick things up so they come out more easily. the main way you do this is by drinking mineral oil. some people think you should substitute natural oils, but there's no point in doing that. if the oil is digestible by humans it won't be a lubricant coming out. mineral oil coats, soothes, relieves, and i was pretty grateful for it. finding the right balance of oil can be difficult, though. too much oil will cause incontinence, which is embarrassing at parties. also, feces mixed with oil is one hell of a stainer. mineral oil is very unpleasant to drink. it doesn't taste like anything at all, but the coating, greasy texture hits some post-industrial do- not-drink-this instinct. the trick is cutting it with at least an equal part orange juice and stirring vigorously.

there are some long term doubts about drinking mineral oil. mainly, that it can block the uptake of certain vitamins and other nutrients you need. the way around this is to eat your good food and take your vitamins several hours before or after your mineral oil. you shouldn't drink mineral oil less than an hour after eating anyhow, and you'll find you don't want to. mineral oil is a controversial treatment, but for some people it gets you from slow decline to slow healing. like all medical treatment, you have to weight what you get against the risks.

things you stick up your butt

*muscle relaxers - the main one you will hear about is nitroglycerin ointment, .2% dosage. this is actually what did it for me, and i still use it now- but only it. (yeah!) the common dosage of nitro is 2%, used in patches for heart patients. as with most things, the location of the decimal point is very very important. never, ever ever put 2% up your butt. to get it right you have to go to a compounding pharmacy, rite-aide will not give you the right stuff. you'll know they have it right when they quote you an outrageous price for a compounded medication. most places won't compound aspirin for less than $40, and nitro is no exception. be diligent on this point; double check that you have .2% rather than 2%.

as an alternative for people who get headaches from even the .2% nitro, compounded diltiazem 2% can work. it isn't, IME, as potent. and it takes a little longer to work, but for those who simply can't do nitro it offers another possibility.

i was also given analpram, the worst-named medication ever. what the hell was that marketing department thinking? in addition to invoking images of giant butts in strollers, it didn't help in any way i noticed and it hurt to apply. so i stopped using it, c'est la vie. for some others it may be a lifesaver, i don't know.

applying topical medications to the anus

i got this one wrong for a while because people were being coy with me. "um," they would say, "apply this to the anus," they would say. sometimes they would look nervous and coyly add "um. thoroughly." well, coy ends here. applying nitro isn't putting a pea sized bit of ointment right on the little pucker and having a poo while unicorns and rainbows fill the bathroom. you have to get down to the business of getting that stuff up and in. you have to work your finger up your butt while squatting or bending over. you have to do something that requires keeping your nails short. it coats your finger, and if you are getting it into the right spots your finger simply isn't going to be clean anymore. i find that the time to wipe off my finger and go over to the sink and scrub the hell out of it is about right to make sure the medication has a chance to sink in. a nail brush is good. and bleach. bleach is good.

what you can do about the pain

pain meds are mostly constipating. heh! if there is a god, he doesn't like us very much. this leaves us with warm baths. long warm baths. they say 20 minutes, i say 3 hours. your milleage may vary. it's good to have something to read. my baths have ranged between the city recycling pamphlet and russian novel.

diet for a small stool

one friend with a fissure put it this way: you're going for the consistency of toothpaste. the main way you get soft is by "bulking up" and being regular; the main way you do that, diet-wise, is eating lots of fiber. take fiber, eat fiber, go fiber crazy. and don't eat the bad bowel foods- heavy fats like butter, meats and cheese. "but!" i hear you cry; "that's my whole diet!" yeah, that's why you have an anal fissure.

conversely you may be already be deep in the fiber, which i was. raw broccoli and carrot sticks have been my staples for ages, so i was pretty bitter about getting the diet talk. however i did learn to spread my fiber through the day better. i get at least 12 gms per 1000 calories, and usually much higher in the course of the day, and i note the fiber content of every meal. since i'm on a vegetarian high-protein diet (as a nursing mother) this can be tricky, but two words have come to my rescue: soy beans.

sadly, this like most other gi disorders means you can't safely eat mexican food. and chili, hot lovely chili... that's a good way to loose a week of you life/a pint of blood.

a word about beans and other "fermenting fibers"

eating a high-fiber diet for many seems to mean farting all the time. this isn't a problem that can be solved by hanging out with the kind of people who think a keg, you, and a lighter make for a pretty funny saturday night, because passing gas with a fissure can really hurt and delay healing. the trick is to go in for non-fermenting fibers, like citrucil. metamucil and kidney beans can be deadly, but soybeans and carrots and citrucil can save the day. keep a food diary and figure out what gives you gas and what doesn't.

learning to relax

nowadays, when someone asks me which finger i keep up my ass, i can answer them. first the application of the medicine, and then trying to learn to relax the sphincter more so that i don't need the medicine as much, and so that i become less likely to tear again in the long term, or when i'm trapped in a plane lavatory with a baby tied to me. both my doctor and other people who probably would rather not be identified here advised touch relaxation. this means getting into a good position, like squatting, and touching around the anus with your finger. as you touch areas, consciously relax the area you touch. proceed up the anus with your finger, relaxing each part as you go. if it's bothering you don't think about your finger, you can wash it later. you've stuck your finger in worse, probably at taco bell. start this exercise with relaxing medication like nitro, but try it later without nitro as well. if it hurts, stop. start again if you need to, but never go past the point where it hurts. after all, what's the point of ripping yourself with your finger?

the truth is it took a long time for me to start doing this. i was in so much pain the thought of touching myself down there was unbearable. and, for the love of pete, they were telling me to shove my finger up my ass. but in time it wasn't as bad, and i'd lost a lot of shame anyhow. learning to do this squatting and then sitting on the toilet saved me from re-tearing when i had to go and i didn't have my medication. for this i am grateful.

really learning to relax: botox

botox injections aren't just for middle aged rich women in denial anymore! now, in the age of modern miracles, you can get botox injections in the anal sphincter to allow absolutely anything to pass through unhindered. need to pass a piano? botox is your pathogen. truly, botox injections can be very good, provided two things: 1. you have a non-recurring fissure, and 2. the person administering the shot is experienced enough to not give you a thrombosed hemorrhoid. there is always a danger that each injection point will become as bad the the fissure itself. you simply don't go to a cosmetic botox person and say, "can i have the special, only in the ass?" think gastroenterologist or bust. also, botox doesn't prevent you from getting another anal fissure. for that, you have to go the distance.

the distance: lateral internal sphincterotomy

at first i was terribly mixed up and calling this a lateral internal sphincterectomy. that would be a very bad idea, it turns out. remember, kids: -otomy scrambles the bits, like a lobotomy, -ectomy takes 'em out, like tonsillectomy. getting those mixed up can lead to all sorts of wacky hijinx. but back to the laiteral internal sphincterotomy. it involves cutting the muscle that basically is the anus, and thereby achieving the ultimate relaxed state. it's a surgery with a good prognosis. well over 90% of people that get it will never have another fissure, and 100% of them had a really bad problem, i can guarantee. this is because somewhere between 10-30% of them have some sort of lasting incontinence problem. the main problem i've heard of is an inability to distinguish between gas and liquid. it's a tough call; a life of excruciating pain, or the endless possibility of beating everyone else's "dates from hell" anecdotes. this is why it's a good idea to exhaust all the non-surgical options first, and why it is very important to insist on experienced physicians if it comes to surgery. no surgeon worth their salt will balk at telling you how many times they've performed a procedure, or how many people have had to come back for further help; if they do, find a new surgeon. get your surgeon's number of procedures and number of people that have had trouble afterward, go home and cross reference that by how much hellish pain you are in and how long you've tried other therapies, and decide.

past the distance: dilation

anal dilation is a lot like sphincterotmy, except: 1. it often doesn't work, and 2. it often makes things worse. it's an outdated idea that was never very good in the first place. the idea is to shove something up the butt and expand it, pulling and stretching (sometimes tearing) the muscle to achieve the same effect as cutting it in a lateral sphincterotomy. the idea is pretty much as bad as it sounds, and has roughly the effect you think it would. skip. if you've read other medical webpages on this site you'll notice that i am very deferential to the experience of doctors; i advise seeing them and listening to them, i point out repeatedly that they are the experts. i will almost never contradict a doctor, but anal dilation these days is just stupid.

ending on a positive note

anal fissures range in pain from being so deep in that language is no longer possible to being mildly annoying. these days, i can live with mine, though some days are better than others. in the beginning some of my pains were worse than my labor. it gets better very slowly, but it does get better. best of all it's not actually a dangerous illness. there's no danger of infection unless you are already immunosupressed. there's no knock-on dangers to other parts of your gi tract. it's never going to kill you, and though there may be days when that's all you can say, you can say that for sure.