Patients often have an anal fissure rather than haemorrhoids.
An anal fissure is a tear in the anal canal. It may arise after passing a particularly hard or large bowel motion or after anal trauma. It gives symptoms of bleeding and itching, like haemorrhoids, but is often much more painful.
It is thought by many that the painful spasm of the anus reduces the blood supply to the anus, which prevents normal healing. Treatment options include laxatives and special prescription creams that work by relaxing the anus to theoretically allow more blood to get to the fissure.
In a significant group of patients these creams do not work. One problem is that a side-effect of the creams can be headaches, and the patient therefore stops using the cream. Instead patients should be advised to use less cream until the headaches are not too bad, and they should use a rubber glove to apply the cream so that they don’t absorb extra cream in their fingertip. The course of the cream treatment is usually 8 weeks so patients should be advised to diligently use the cream for 8 weeks even if they are feeling much better before that. This is because the fissure can reopen if it is not allowed to heal completely.
In patients where the creams do not work specialist surgery can be helpful. A sphincterotomy operation cuts a part of the anal sphincter, thereby relaxing the anus and again helping blood to get to the fissure for healing. Another operation is injection of botulinum toxin (sometimes called botox) into the anus to again relax it. This operation can be contraindicated in patients with previous sphincter damage, such as women with childbirth muscle injury. An endoanal ultrasound scan can check the state of the anal sphincters before any surgery in these patients at risk.