Hemorrhoids and anal fissure accounts for more than 70% of anorectal diseases, the major clinical manifestation of the two diseases are pain or itching, long defecation time and difficulty in defecation.
Anal Fisür

Anal Fissure

Anal fissure is a tear or crack in the skin that lines the opening of the anus (rectum). In the first month, the tear is an "acute anal fissure", whereas if the tear is present for a longer duration and accompanied by a lump, it is a "chronic anal fissure".

Causes

  • The most important cause is to strain the anal mucosa more than it can handle, which is usually because of constipation . As a result, hardened stool tears the lining while being pushed out.
  • Severe (long-term) diarrhea may cause straining and cracking.
  • Forced enema or a hard object pushed through the anus (e.g. ultrasound probe used in prostate examination)
  • Strained rectum due to the pressure applied by the unborn baby during the last months of the pregnancy or during childbirth
  • Diseases (e.g. Crohn's disease, anal cancer) or infections (e.g. herpes)
  • Genetic factors

Note: Fissure and Fistula are different complications. In cases of Fistula, discharge flows through another hole (fistula channel) about 2-4 cm to the rectum.

Symptoms of Anal Fissure

  • The most prominent symptom is the pain. The strain in the sphincter muscles at the rectum causes the pain. There are sharp pains during or after passing stool.
  • Some patients might have bleeding. For this reason, one may mistake fissure for hemorrhoid. There is a higher probability of seeing blood in the cases of anal fissure in children.
  • There can be a lump next to fissure scar. (The patient may misinterpret it in favor of hemorrhoid.)
  • In some patients, itching can be observed, which is the mildest stage of pain.
  • Some patients may have a foul-smelling discharge.

Anal Fissure Treatment Methods

  • General treatment: Diet and immersing your body into hot water (sitz bath). Diet and medication will help if there is diarrhea or constipation. If the fissure is not at a very advanced stage, this shall help.
  • Pomades, ointments and suppositories:
    • Numbing pomades: are advised to numb the area. They comprise lidocaine and similar drug substances.
    • Ointments with nitroglycerine: relieve the strained sphincter muscle and decrease the pressure on the anal region. They might have adverse effects such as low blood pressure and severe headache.
    • Ointments with diltiazem or nifedipine: They have been used since 1999 to relieve the muscle that causes the pain. Usually these ointments contain compounds with drug effects. The success rate of these ointments in early stage fissures is 73 %.
    • Ointments with steroids: They are prescribed if inflammation is observed. However, use of such ointments for more than 2 weeks result in thinning of the anal lining and may result in a worsened condition.
  • Botulinum toxin (botox): is applied to relieve the strained sphincther muscle that causes the pain. The success rate is around 75 %. During the time the pain is relieved by the botox, the fissure should be treated otherwise your complaints will continue when the effect of the botox wears off. It has been used since 1993 in the treatment of anal fissure.
  • Treatment withNCAREWhite Peony Tablet: It has been used since 1996 in countries such as China, Japan, Russia, USA. It has been available in Turkey since 2009 in selected pharmacies as supplement and on the website.
    Advantages:
    • For treatment, using 1 or 2 box(es) usually suffice.
    • It does not have any risks or life-threatening adverse effects.
    • It is easy to use because it is taken orally. It can be used by all age groups.
    • Clinical success rate is around 94%, which is higher than botox and surgery.
    Disadvantages:
    • It does not relieve the fissure-related pain immediately on the day of administration. Its effects mostly begin within the first 7 days.
    • It is an over-the-counter drug, therefore it is not included in the prescription drug coverage and paid by the user.
    • It should not be used alongside painkillers and other drugs to treat anal fissure.
  • Treatment withNCAREPoint Cream: You may buy online at NCARE website.
    Advantages:
    • It does not have any risks or life-threatening adverse effects.
    • It can be used by all age groups.
    • It will relieve in a few hours.
    Disadvantages:
    • Treatment period is not short; It should be used at least 7 days.
    • It is not included in the prescription drug coverage and It is paid by the user.
  • Treatment with other drugs:
    • Painkillers: are used for relief, not for treatment. Usually the painkillers with flurbiprofen as the active ingredient are preferred.
    • Venotropic medications (e.g. Daflon): These drugs sold under prescription will relieve the rectum and are effective if the case is in its early stages. Usually suggeted to be used alongside hot water bath. If no visible effect observed within 15 days of use, the patient should consult a physician.
    • Herbal products as remedies for fissure: Usually contain plants such as black myrobalan (Terminalia nigra) and horse chestnut (Aesculus hippocastanum). These plants have relieving effect due to their vascular strengthening and vasoconstrictor properties, however they are not curative.
  • Surgery (lateral internal sphincterotomy): is the most preferred modality of surgery for anal fissure. Success rate is high. The strained sphincter muscle causing the pain is dissected and the pain is relieved, with the blood flow directed towards the perianal region. However there can be cases of fecal incontinence (1%), inability to control feces (8%) or gas (20%). Figures in the parenthesis refer to the percent of cases experiences the corresponding adverse event.
  • Surgery (anal dilation): is not a highly preferred surgical operation. It aims to relieve the pain by stretching the anal canal. However, it can cause trauma in the anus and may result in inability to control feces up to 20%. Its success rate is 72%.
  • Injection: Injections to relieve muscles decrease the pain. It is not a curative treatment but provides temporary relief.

Note: Methods to prevent fissure are explained at the end of the page (below).

Hemorrhoid

It is the swelling of the veins around the rectum (anus) at one or more regions. It is also commonly known as piles.

Causes

  • Postponing the need to go to the toilet: If the stool is kept against the urge, it may harden; causing it to hurt the vein while passing and thereby leading to hemorrhoid.
  • Constipation or pushing too much and too hard (to strain)
  • Circulation problems: Obesity, choice of profession (driver, hairdresser, etc.), standing up for long hours, sitting for long hours
  • Persistent diarrhea
  • Pressure during pregnancy or childbirth
  • Irregular eating, poor fiber intake, insufficient water intake
  • Tumor in pelvis (lower abdomen): It may apply pressure to anal canal and induce hemorrhoids.
  • Genetics: Genetically long intestines trigger constipation, causing hemorrhoidHemoroit
  • Advance age: Half of people who are older than 50 seek treatment for hemroids.

Types and Stages

There are two types of hemorrhoid: internal and external. Bleeding (bright red blood), itching, burning are the most common symptoms.
  • Internal hemorrhoid: It is the varicosis of the inner vein. It has 4 stages:
    • 1st stage: The internal hemorrhoid pile is not big enough to palpate (not felt when examined by hand). There could be bleeding and burning (pain).
    • 2nd stage: The pile bulges out of the anus while passing stool but then recedes back into the rectum on its own. There could be bleeding.
    • 3rd stage: The pile that bulges out of the anus while passing the stool cannot retract. It can only be gently pushed back in with a finger.
    • 4rd stage: Exposed pile in no way recedes back into the anal canal. It permanently remains bulged out of the anus.
  • External hemorrhoid: It is the dilatation of the vein just outside the anal exit. There is constantly a pile bulging out of the anus and it can be felt by hand. In 4th stage internal hemorrhoid, there is a pile originating from inside and lumping out of the anus which cannot be pushed back inside, while in external hemorrhoid there is a pile outside of the anus. If this pile has blood clotted inside, this is a thrombosed hemorrhoid and that can cause pain.

Hemorrhoid Treatment Methods

  • General treatment: Diet and immersing your body into hot water (sitz bath). Diet and medication to eliminate diarrhea or constipation, if any. Immersing your body into hot water aims to constrict the veins and shrink them. Body is immersed into hot water at least 3 times a day for 20 minutes, for 1 week. It is usually relieving and can treat if the complication is in its early stages.
  • Pomades, ointments, and suppositories: They are vasoconstrictive, softening, numbing ointments.
    Management of thrombosed or infected hemorrhoids include ointments with antibiotics. In the treatment of internal hemorrhoids, ointments are squeezed towards inside of the rectum using the provided apparatus. They are relieving and usually can be curative if the complication is in its early stages.
  • Treatment withNCAREWhite Peony Tablet: It has been used since 1996 in various countries. It is effective in the treatments of both internal and external hemorrhoids.
    Advantages:
    • Using 1 or 2 box(es) usually suffice for cure.
    • It does not have any risks or life-threatening adverse effects.
    • It is easy to use because it is taken orally. It can be used by all age groups.
    • Clinical success rate is around 95 %.
    Disadvantages:
    • It is an over-the-counter drug, therefore it is not included in the prescription drug coverage and paid by the user.
    • It is not enough to treat 4th stage internal hemorrhoid on its own. Concomitantly, NCARE Point shall be used.
    • It should not be used alongside other ointments, suppositories and drugs used to treat hemorrhoid.
  • Treatment withNCAREPoint Cream: It is effective in the treatments hemorrhoids.
    Advantages:
    • It does not have any risks or life-threatening adverse effects.
    • It can be used by all age groups.
    • It will relieve in a few hours.
    Disadvantages:
    • Treatment period is not short; It should be used at least 7 days.
    • It is not included in the prescription drug coverage and It is paid by the user.
  • Treatment With Other Drugs:
    • Painkillers: are used for relief, not for treatment. Usually the painkillers with flurbiprofen as the active ingredient are preferred.
    • Venotropic medications (e.g. Daflon): These drugs sold under prescription will relieve the rectum and are beneficial if the case is in its early stages. If no visible effect observed within 15 days of use, the patient should consult a physician.
    • Other herbal products as remedies for hemorrhoid: Usually contain plants such as black myrobalan (Terminalia nigra) and horse chestnut (Aesculus hippocastanum). These plants have relieving effect due to their vascular strengthening and vasoconstrictor properties. They are capable of cure in individuals with initial stage of disease whereas they provide relief to patients with advanced stages of hemorrhoid.
  • Simple Surgical Operation:
    • Infrared coagulation: Also known widely as "burning with laser therapy", it can be applied to 1st, 2nd, and 3rd stage hemorrhoids. It is an expensive method.
    • Rubber band ligation: involves tying off the hemorrhoid with a rubber band. It can be used in the treatment of 1st, 2nd and 3rd stage hemorrhoids, and rarely for 4th stage hemorrhoids. A special rubber band is tied to the hemorrhoid pile and hemorrhoid falls of within a couple of days. A small but unnoticeable scar will remain, which disappears after a short while. It does not require anesthesia. This method can be applied office setup.
    • Sclerotherapy: is the injection of drug into the hemorrhoid pile. It can be used in 1st, 2nd, and sometimes 3rd stage internal hemorrhoid treatment. This drug causes the pile to shrink and recede to its normal condition. There can be bleeding and increased irritation. Physicians perform it in office setup and usually requires 1-2 weeks recovery time. During this time, there can be swelling with some pain, and discharge with little amount of blood. If not performed properly, blood may clot the veins. The cost of treatment depends on the amount of drug injected.
  • Surgical Treatment: There are several methods, which all converge on the surgical removal of hemorrhoids. It has many side-effects and long recovery time but the success rate is significantly high. Especially used as treatment of painful hemorrhoids and 4th stage internal hemorrhoid. It must be performed by an experienced specialist.

Hemorrhoid and Anal Fissure Prevention Methods

  1. Habit of eating regularly, drinking at least 8 glasses of water a day and consuming foods rich in fiber
  2. Avoiding constipation
  3. Avoiding straining while on toilet
  4. Helping the digestive system: e.g. daily exercise or 20 minutes of walking a day
  5. Avoiding activities that cause problems in circulation such as sitting for long hours or standing up for long hours
  6. Avoiding activities that result in high pressure at the rectum (e.g. persistent diarrhea, lifting heavy weight, anal intercourse)
  7. Going to the toilet regularly every day. The ideal is to have the bowel movement every morning after breakfast.
  8. Avoiding foods that are not compatible with or unhealthy for your metabolism

"I want an end to my discomfort, never to go through this again." Which treatment can ensure this?
Just because your hemorrhoid or anal fissure is treated, does not necessarily mean you will never go through this again.
Even if you underwent surgery or used medication; unless you adopt the abovementioned 8 prevention methods as your lifestyle, your discomfort can recur.

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