I'm having a very hard time healing anal fissures. I would like to avoid surgery because it seems drastic. Yet the pain is excruciating and bleeding/clotting frequent. Is there anything I can do to relieve the pain? I am very large and arthritic and cannot take sitz baths.

K.G.

Anal fissures are breaks in the skin that lines the anal canal. They occur most commonly in young people, usually because of the passage of a hard stool that traumatizes the anus. Most patients who develop anal fissures have a higher-than-normal pressure in the anal canal. In a small percentage of cases, anal fissures stem from other causes, such Crohn's disease or certain infections.

The main symptom of an anal fissure is pain with defecation, which improves soon after the stool is passed. The patient may also notice some bleeding and itching at the anus. The therapy for anal fissures varies depending on how long the fissure has been present. Acute fissures are easier to heal because they have been present for a shorter length of time and have not yet caused a significant amount of inflammation in the surrounding tissues. The therapy for acute fissures includes sitz baths, suppositories and stool bulking agents to treat constipation. Topical nitroglycerin ointment can also provide a great deal of pain relief. With such treatments, acute fissures will heal in four to eight weeks in most patients.

For fissures that do not heal, surgical therapy is often required. This procedure essentially involves a controlled disruption of the internal anal sphincter, thus leading to a lower pressure in the anal canal. It is felt that lowering this pressure will prevent further fissures from forming by improving blood flow to the anus. With surgery, the fissure typically heals in one to four weeks and remains healed in 95 percent of patients. The most common side effect of the procedure is minor fecal incontinence, affecting up to 15 percent of patients.

The newest therapy for anal fissures is botulinum toxin (botox) injections. Botox is a bacterial toxin that causes muscle paralysis when injected. In people with anal fissures, botox is injected into the anal sphincter to lower the pressure and allow the fissures to heal. Early data show that this therapy is effective in healing fissures in more than 70 percent of patients and in improving symptoms in more than 80 percent of patients after just one or two treatments. Long-term data are not yet available, but there is certainly a great deal of optimism about this nonsurgical therapy for anal fissures. You should discuss the available treatment options with your doctor.