FAMILY MEDICINE® COLUMN
By John C. Wolf, D.O.
Associate Professor of Family Medicine®
Ohio University College of Osteopathic Medicine

MORE FIBER, LESS SPICE CAN KEEP RECTAL FISSURE FROM RECURRING

Question: My grown daughter, age 26, was recently diagnosed with an anal fissure. The doctor prescribed a stool softener and some kind of cream to be applied to the rectal area. She told my daughter that this was a problem that was likely to recur. Is there anything that can be done to make a recurrence less likely? Can a change in diet help? My daughter is a vegetarian and says she already eats lots of fiber.

Answer: The condition you ask about -- a rectal, or anal fissure -- is actually a tear of the skin-like lining (mucosa) of the rectal canal. Those who suffer from this problem, like your daughter, have pain with the passage of a bowel movement. The pain usually persists for several minutes afterwards, and the rectal area is quite tender when touched during wiping. There is usually some accompanying rectal bleeding as well. This typically quits with the passage of the stool.

With the first episode of rectal fissure, many sufferers report experiencing a tearing sensation while straining to pass a firm bowel movement. Yes, that is exactly what happens -- the rectal canal is unable to stretch sufficiently to pass that large stool. Consequently, the mucosa tears. The tear of the rectal mucosa almost always occurs in what doctors call the "posterior surface" of the canal, the region near the tailbone. This happens somewhat more often in children and young adults than in older individuals. It is also somewhat more common in women.

A rectal fissure is diagnosed by the history of when and how the pain started and the relationship of bleeding to bowel movements. In addition, it is necessary to look at the rectum. Your doctor can often see the edge of the tear without the use of instruments. At other times, the use of an instrument called an anoscope is necessary. When your doctor needs to use an anoscope, he or she will usually apply an anesthetic lubricant to minimize discomfort.

I know that none of this examination sounds very pleasant, but it is important. Most causes of rectal pain and bleeding are not life threatening, but delay in treatment certainly prolongs your discomfort and may also allow the condition to worsen, thereby, requiring more drastic forms of treatment.

A rectal fissure that has been present for a matter of a few weeks can usually be successfully treated with the use of a combination of measures. Sitz baths two or three times a day can help calm down the acute discomfort as will the use of topical "hemorrhoid" cream. More important is making sure that the bowel movements become soft so that they do not traumatize the healing fissure.

Following a vegetarian diet typically provides the recommended 30 grams of fiber each day that we should all eat, but it would be wise to add additional fiber because of the fissure. Products like Metamucil, Fibercon and Citrucel work nicely for this purpose. In addition to fiber, it is important to drink large amounts of liquids to keep the stool soft. The color of your urine is the easiest way to determine if you are drinking enough water. If it is dark, you need to drink more water. Another common cause of constipation is holding off having a bowel movement. Of course, waiting a few minutes is okay, but you shouldn't hold off until the end of your workday. Go when you have the urge.

In addition to fiber and water, it is important to avoid foods that can cause additional rectal irritation. Very hot spicy foods are examples, as are poorly chewed nuts.

Following these simple treatments can allow the healing of the fissure and prevent its recurrence. Fissures that persist for more than three months despite these treatments may require surgery. Fortunately, this is rarely necessary.

Family Medicine® is a weekly column. To submit questions, write to John C. Wolf, D.O., Ohio University College of Osteopathic Medicine, Grosvenor Hall, Athens, Ohio 45701.