An article in the New England Journal of Medicine shows that most cases of rectal cracks, called fissures, can be cured by an inexpensive nitroglycerin cream or an injection of botulinum toxin (1), but doctors will continue to cut them out because insurance companies pay 750 dollars or more for surgery, while they pay only for the cost of a routine office visit for prescribing the creams or injections.
If you have rectal pain or bleeding, check with your doctor. The odds are overwhelming that you have a fissure or a crack in your rectum that can be cured with antibiotics and a topical nitroglycerin cream. If your doctor does not find hemorrhoids or fissures, you must have a tube inserted into your colon to check for other causes of bleeding such as cancers, since one in four cases of rectal bleeding not caused by fissures or hemorrhoids is caused by serious disease (2). If you have a small crack called a fissure or large veins called hemorrhoids, you can often be cured by applying a special ointment made by mixing one part of the commercially available (by prescription) 2% nittroglycerin ointment with 20 parts of Vaseline (3,4,5,7,8,10). If you do not dilute the nitroglycerine, it can cause headaches. I also recommend that both you and your partner take a long-acting erythromycin (azithromycin 250 mg once a day for 9 days).
Fissures, hemorrhoids and anal itching are almost always infected (8), so they should be treated with antibiotics (9). Hemorrhoids are caused by a tight sphincter that squeezes the arteries and veins as they carry blood to and from the last part of the intestines. Since pressure in arteries is much greater than that in veins, the arteries remain open, while the veins collapse, increasing pressure in the veins and causing them to widen, hurt and bleed. Surgery is rarely required and they usually return after surgery anyway. Hemorrhoids may be treated by using a balloon to widen the sphincter or mechanically stretching the sphincter under anaesthesia (6).
If you have rectal bleeding and do not have hemorrhoids or fissures, your doctor will probably order a special X-ray called a barium enema. A ten-year follow up on patients with rectal bleeding without obvious cause showed that 13 percent had polyps that can turn into cancer, four percent had inflammatory bowel disease that can cause terrible cramping and gas, and 6.5 percent eventually developed colon cancer (2).
1)) Brisinda G et al. A comparison of injecitons of botulinum toxin and topical nitroglycerin ointment for the traetment of chronic anal fissure. NEJM,July 8, 1999. 341:65-69.
2) Gelfand M et al. History of visible rectal bleeding in a primary care population. JAMA, 1997(Jan 1);277(1):44-48.
3) SR Gorfine. Treatment of benign anal disease with topical nitroglycerin. Diseases of the Colon & Rectum 38:5 (MAY 1995):453-457.
4) WR Schouten, JW Briel, MO Boerma, JJA Awuerda, EB Wilms, BH Graatsma. Pathophysiological aspects and clinical outcome of intra-anal application of isosorbide dinitrate in patients with chronic anal fissure. Gut 39: 3 (SEP 1996):465-469. Local application of ISDN reduces anal pressure and improves anodermal blood flow. This dual effect results in a fissure healing rate of 88% at 12 weeks.
5) Lund JN et al. A randomized prospective double blind placebo-controlled trial of glycerol trinitrate ointment in treatment of anal fissure. Lancet, 1977(January 4);349(9044):11-13.
6) NI Alstrup, OO Rasmussen, J Christiansen. Effect of rectal dilation in fecal incontinence with low rectal compliance: Report of a case. Diseases of the Colon & Rectum 38: 9 (SEP 1995);988-989.
7)H Bacher, HJ Mischinger, G Werkgartner, H Cerwenka, Elshabrawi, J Pfeifer, W Schweiger. Local nitroglycerin for treatment of anal fissures: An alternative to lateral sphincterotomy? Diseases of the Colon & Rectum 40: 7 (JUL 1997):840-845. Take azithromycin 250 mg per day for 6 days and use diluted 2% nitroglycerin diluted 1/20 twice a day for a week or two.
8)J Lysy, Y Israelityatzkan, M Sestiereittah, D Keret, E Goldin. Treatment of chronic anal fissure with isosorbide dinitrate: Long-term results and dose determination. Diseases of the Colon & Rectum 41: 11 (NOV 1998):1406-1410.In our experience the optimal dose regimen is 2.5 mg three times each day.
9) MLJ Bafounta, P Bloch, S Kernbaum, P Saiag. Group A beta-hemolytic Streptococcus: an exceptional etiology for perianal dermatitis in adults? Annales de Dermatologie Et de Venereologie 125: 12(DEC 1998):902-904.
10) NH Hyman, PA Cataldo. Nitroglycerin ointment for anal fissures - Effective treatment or just a headache? Diseases of the Colon & Rectum, 1999, Vol 42, Iss 3, pp 383-385.
11)ML Kennedy, S Sowter, H Nguyen, DZ Lubowski.Glyceryl trinitrate ointment for the treatment of chronic anal fissure - Results of a placebo-controlled trial and long-term follow-up.Diseases of the Colon & Rectum, 1999, Vol 42, Iss 8, pp 1000-1006.
12)M Minguez, F Melo, A Espi, E GarciaGranero, F Mora, S Lledo, A Benages.Therapeutic effects of different doses of botulinum toxin in chronic anal fissure.Diseases of the Colon & Rectum, 1999, Vol 42, Iss 8, pp 1016-1021.
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