Patient 30

Date: Sun, 11 Feb 2001 16:45:10 -0500
To: jackfaf6.arc.nasa.gov
Subject: Optimistic story from a fissure patient

Dear Jack,

• Nitroglycerin ointment helped me a lot, but I've found that it has to be in at least 0.4% concentration to work well. This is consistent with the way I react to most prescription drugs; usually they have to hit me with about twice the dosage a normal person my size would need. (For an extreme example, it usually takes 5 to 10 injections for me to respond to local anesthetics for dental work.) I get a mild headache from NTG, but it's transient, and much less painful than the fissure is! I've also found that latex finger cots make the job much more pleasant. :-)
• That said, the REAL miracle drug for me has been the calcium-channel blocker nifedipine (generic for Procardia), taken orally. I had a miserable flareup of the fissure about a month ago, and after two weeks of pain, got a prescription for 10 mg nifedipine softgels. For the first week, I swallowed at least 5 or 6 a day; two after each BM and one every time the sphincter spasm kicked in. I also recharged some of my old, wimped-out NTG ointment by puncturing a nifedipine capsule and mixing some of the liquid into it. It was as effective locally as NTG, and didn't produce so much of a headache. It's now two weeks after I started nifedipine. The fissure has healed and the spasms have been vastly reduced. By the way, premenopausal women may want to know that because nifedipine is a smooth-muscle relaxant, it also did wonders for my menstrual cramps.
• I've found that I'm prone to rectal spasms, with or without an unhealed fissure, if I'm under a lot of stress (for example, while I'm driving in very bad weather conditions). Oral nifedipine helps end the spasm. Finding other ways to manage the stress helps prevent the spasms from happening in the first place.
• Large doses of caffeine are definitely a problem. With regard to provoking rectal spasms, a single cup of coffee or tea doesn't seem to be a big deal for me, but I've found out the hard way that a double espresso sure is! I'm reducing my caffeine consumption for the time being, from perhaps four cups of coffee a day to the equivalent of one. By dividing my caffeine dose (like mixing regular coffee with decaf) I've remained surprisingly free of caffeine-deprivation headaches.
• A small amount of alcohol (like a glass or two of wine with dinner), being a relaxant, seems to help me. The usual caveats about moderation, of course, apply. Also, there are two other things to consider if you choose to drink alcohol. One: Like caffeine, alcohol will dehydrate you if you don't increase your water intake accordingly, and dehydration can cause constipation. Two: If you're on nifedipine, stay away from alcoholic beverages until you know for sure how the nifedipine affects you. (According to the label on my prescription, alcohol isn't completely contraindicated with nifedipine -- I'm sure lots of heart patients who take it also do the red wine thing -- but the pharmacist's information does suggest limiting alcohol). Especially with the first few doses, nifedipine can cause dizziness, and you don't want to aggravate that if you have to be vertical and functional. (By the same token, if you're trying nifedipine, don't drive during its peak effect, at least until your body gets used to it!)
• I'm not fond of cold drinks and have always absolutely HATED to drink water, whether it's tap water or the fancy bottled stuff, but I'm learning very quickly to love it instead. I'm convinced that dehydration is the root cause of my fissures. There's no reason in the world why I should ever have a problem with constipation, since my diet is largely made up of a variety of vegetables and whole grains. However, I frequently forget to drink anything during most of the day. I'm now making a big effort to drink 48 to 64 ounces of water a day, as well as other sugar-free, non-caffeinated beverages like herbal tea. Combined with twice-daily doses of Metamucil equivalent (I buy the cheaper drugstore brands) and docusate stool softeners at night, this has made a big difference.

So -- hope I can help other folks out there. This group has definitely helped me, especially in exploring alternatives to surgery. Thanks for providing this resource!

An update from Patient 30:
12/31/07

Hi, folks! I haven't written in a while, but just wanted to update the story with my recent experience.

Since I last wrote, I've had a few flareups of my anal fissure. Usually, a few weeks of oral nifedipine, nitroglycerine ointment, or both has been sufficient to heal the fissure. That is, these things were sufficient until early October of 2006, when I first experienced the Flareup From Hell.

I knew this one was worse when neither nitroglycerin nor nifedipine made a dent in the pain or spasm. It started a month after my 50th birthday, when I needed to schedule a screening colonoscopy, and when the fissure persisted for several months, my physician suggested that a colonoscopy was not only a good idea for general maintenance purposes, but might help diagnose the problem. So he referred me to a gastroenterologist, who suggested that I try a few weeks of warm baths and Calmoseptine ointment to settle things down before he subjected me to a pre-colonoscopy bowel prep.

A few weeks of warm baths and Calmoseptine most emphatically did not settle things down, so my gastroenterologist referred me to a colorectal surgeon, who noticed that the fissure had split open all the way down to the underlying muscle fibers. The surgeon and I discussed the pros and cons of surgery vs. more conservative treatment, and I opted for Botox. So, in March, I got my first Botox treatment (ouch!) It helped for a few weeks, but when it wore off the fissure was most definitely still unhealed. Also, I was starting to have bouts of bleeding that lasted a day or two. This would make the fissure feel better for a couple of days afterwards, but the pain and swelling would always come back. So, in June, I went back to the surgeon for another round of Botox. He suggested that I might have an abscess, but couldn't see it with an anoscope, so we went ahead with the injections.

When I went back for a post-Botox checkup in August, the fissure still hadn't healed, and I was still having bouts of bleeding. This time, my surgeon saw the abscess right away. It turns out the fissure had led to a small fistula, which would drain periodically on its own but was clearly not ever going to heal by itself. So, I had a minor surgical procedure done in August to drain the fistula. We discussed sphincterotomy, but since one possible complication of this surgery is "urgency" and I was soon to take off for a three-week, hotel-hopping vacation in Italy, we decided to start with fistulotomy alone. This seemed to help, but about a month after surgery, while traveling, I hoisted my backpack to my shoulders at a train station and immediately felt as though I'd really torn myself a new one. Fortunately, I had sufficient pain meds with me so that this didn't ruin the second half of my vacation. Unfortunately, it only got worse after I returned home, and a quick examination revealed that the fissure was still unhealed and the abscess was back. My surgeon's opinion was that it would have happened, backpack or no backpack, because the spasms had returned, which prevented the fissure from healing and set up another infection in the same site as before.

So, in mid-October I had my surgeon do the triple whammy. First, a colonoscopy (no other problems found), second, a repeat fistulotomy, and third, a lateral sphincterotomy. Although any anal surgery is likely to leave you sore for a while, I noticed that I wasn't quite as sore after this one as I was after fistulotomy alone in August. After three or four days of the usual thrice-daily sitz baths, going to the bathroom in the morning was much less uncomfortable and I needed much less pain medication.

Three weeks after surgery, the fissure had healed completely. The site of the fistula took a little longer, and is still prone to minor irritation three months later, but good hygiene and a little Calmoseptine keep it under control. I do have some scar tissue left from the whole experience, which my surgeon thinks is responsible for the occasional irritation, but no other problems - no urgency or incontinence, no bleeding, no spasms, and, best of all, no significant pain.

In retrospect, I'd probably have had the surgery sooner if I knew how well it would work, but I'm also glad that I found a surgeon who was willing to work with me on less invasive options first.

Best wishes to everyone for a fissure-free 2008,
Patient 30