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Anal fissure, fistula

Posted by Walt Thompson on Tuesday, 14 April 2015 in Your Questions Answered - NEW! 0 Comments

4/13/ 15

Dear Dr.

It is now 8 months since I had fistula surgery. I am feeling pain at the site of surgery—itching and burning sensation and sometimes pinching pain around the anus—. My doctor has given me Botox injection to treat the fissure, but it converted into a fistula. So I returned to surgery. Is it the side effect of Botox, or was my surgery not successful?


Dear ----,

Before attempting to answer your questions, let us look at the normal ways the body functions in regards to the rectum and anal area.

The anus is the exit point from which the waste material from the food that we put into our body at the mouth leaves. Food taken into the mouth is chewed, mixed with digestive enzymes, swallowed and carried down through the esophagus (gullet) to the stomach. In the stomach it is mixed with more digestive chemicals and enzymes and churned by the muscular action of the stomach. When processing is complete, the contents are emptied into the first portion of the small intestine (duodenum) where more chemicals and enzymes and bile from the gall bladder are added. The contents are then carried through many feet of small intestine where the nutrients are absorbed into the blood stream for transport to other organs. Upon reaching the large intestine, most of the excess liquid is absorbed. Upon reaching the end of the large intestine the contents accumulate in the rectum where they are held until the signal is given to evacuate. Ideally, by this time, if all systems are functioning properly, the bowel contents will be soft, formed, and easily evacuated as the muscles forming the anus relax to permit easy exit from the body.   

In order for these complex functions to occur efficiently, a number of important things must be considered. The ideal diet for efficient digestive function includes mostly natural, unrefined foods, of plant origin. This diet gives bulk, moisture, and important nutrients. For efficient bowel function food should be eaten at meal time only. For people that work in the daytime and rest at night, the first meal of the day should contain about half of the daily nutritional needs. The other half should be eaten later in the day as a single meal, or divided between mid-day and early evening. Ample amounts of water are best taken in between meals to help keep the stools soft. 

Normally, the large meal entering the stomach triggers a “rush” in the entire digestive track, normally resulting in the urge to move the bowels and empty the rectum a half hour or so later. When, then, this urge is responded to, one normally develops a pattern that will help to maintain regular emptying of contents of just the right consistency and regularity. Our bodies do this automatically if they are treated right. If any of these important steps are ignored, problems may eventually be expected—constipation, straining, large, hard stools, etc. Large, hard stools may stretch the anus too far and tear its tender lining. This tear is known as an acute fissure. Unless normal bower function is rapidly reestablished and stools made soft and formed, the fissure may become chronic, causing pain and/or bleeding with each BM. Eventually, unmanaged, an painful ulcer may form. Once established, these problems are self-perpetuating. The pain causes spasm of the anal muscle, causing it to remain very tight and unable to relax to permit the stool, even when soft, to pass easily. For healing to occur, the cycle of pain and spasm must be broken. 

A tear, an acute fissure, a chronic fissure, or ulcer may require professional help if not rapidly responsive to the above described normal digestive functions.

Other factors, too, including emotional stress, may tend to contribute to fissures, ulcers, and fistulas, hemorrhoids and many other uncomfortable and dangerous anal-rectal problems. 

A fistula, unlike a fissure or ulcer, is a communication between the inside of the anus or rectum and the skin around the anal opening. This problem, too, develops in the presence of unhealthful digestive function. Fistulas often begin as an abscess (painful accumulation of pus) that may drain spontaneously or surgically as the case may be, leaving a drainage canal between the inside of the ano-rectum and the skin around the anus. 

Once present, restoration of health promoting life style and natural modalities as briefly described above are mandatory, and may encourage healing. 

Other modalities that may assist in healing anal-rectal fissures, ulcers, hemorrhoids, etc. may be applied. Diet and adequate drinking water such as to create soft, bulky stools are probably the most important. Taking time to respond to the “call” is also critically important for maintaining good bowel function. Stool softeners are usually a “cop-out” and certainly do not contribute to normal digestive function. Analgesic ointments, topical anesthetics, and medications (nitroglycerine, etc.) to relax the anal muscle are sometimes helpful when used together with a health promoting diet and drink. Heat, as may be applied by sitting in a tub of hot water covering the pelvic area, for 10 – 15 minutes 3-4 times daily and before moving bowels may help relax the muscle and keep it relaxed. 

Botox is a chemical that when injected into the spastic muscle of the anus may relax the muscle for several weeks or months, giving time for the fissure or ulcer to heal. Surgically, one can cut the muscle bundle that is in spasm, thus preventing the tight sphincter and permitting the diseased area to heal. Pain relief is often almost immediate with this procedure when used for simple, uncomplicated chronic fissures or ulcers. This procedure can sometimes be done with local injectable anesthesia as an out-patient. 

Now, with this foundation, my response to your question is as follows. Yes, it is possible that a fistula could develop as a complication of treatment of the fissure or ulcer. It is also possible that the fistula is a complication of the other procedures. Many, many other health issues may also be the source of, or contribute to the development of a fistula. Certain types of inflammatory conditions of the bowels can cause fistulas, even apart from other anal problems. Likewise, there are many other health problems that can interfere with healing (diabetes is just one example). 

It is very difficult to know exactly the reason for your problem. Therefore I wish to make the following suggestions. If at all possible, establish life-style practices as described above. 

I would then recommend that you apply the other modalities discussed above for a number of weeks. If these do not resolve your problem, or if symptoms increase in spite of it, I would recheck with your ano-rectal specialist that did the original work—or if uncomfortable with him/her, perhaps consult with another ano-rectal specialist.


(Further information may be found on the web site, www.aplaceofhealing.info, Health Smart, On Line.)

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