By Dr. Kevin Wang
Hello Doctor,
Thank you for helping us with our medical questions.
I am curious to know what is causing an occasional chronic problem I have and would welcome any educated guess you might have.
About three years ago I started having occasional but fairly frequent anal itch and went to the doctor. I also have a mild internal hemorrhoid vein near the anus opening which sometimes makes it uncomfortable when using toilet paper. My doctor suggested a specialist who did an examination. He said, 'Well, I see a very small fissure but you don't want surgery.' I asked, 'No?' He said, 'NO YOU DON'T.' He said to take care of the anal itch I should stop drinking coffee and wash without soap.
Well, I LOVE coffee, and so far I prefer occasional soreness to no coffee. But my question really is this. Sometimes my skin near the anus really itches. If I check it out there is a dampness that stains my underwear and smells. So, what is causing that? I don't think coffee is causing that. And, why is it occasional? Sometimes it seems more common if I have been exercising (which I do only occasionally). Is this smelly, itchy wet skin related to a fissure? Related to hemorrhoid flare up? Related to coffee or acid? Related to lack of fiber? Is it "anal discharge?"
My bowel movements are extremely regular. Same time every day… but, the wet smelly discharge, while occasional, is not attractive if it leaves skid marks in my underwear, or interferes with anal intercourse. It is frustrating because I really, really try to clean well after a bowel movement with toilet paper, and sometimes water, yet still at times I notice later in the day smelly damp discharge there on the skin.
Anything I can do to prevent this, or is it just part of aging? I am 40 now.
Thanks!
– R
PS: Fun question isn't it!? PPS: It is not practical to go back to the specialist again…
Dear R,
Anal fissures are certainly not a laughing matter and it is one of the most uncomfortable things to have! Let's start at the beginning – how it forms, what to do when you have it and some complications that come from having anal fissures for a long period of time.
In most cases, anal fissures occur due to local trauma – passage of hard stool if you're constipated, or use of large dildos in anal play or rough anal intercourse. Once the tear occurs, that area is now weakened and susceptible to repeated injury. When someone has a fissure, that person has pain associated with bowel movements or sex.
In most cases, anal fissures are a temporary nuisance but they can come back quite frequently. To prevent their recurrence, treatment usually consists of fiber supplements, stool softeners, taking of mineral oil to lubricate the stool and warm baths with Epson salts for about a month. For the most part, these fissures usually heal pretty quickly. However, if these treatments don't work, there are medical treatments that include the use of ointments, injections or oral meds to improve blood flow to the area to speed up healing. As a last resort, surgery can be done but it runs the high risk of incontinence and tears.
As far as hemorrhoids, since they were mentioned in your letter, they are caused by the dilation of the veins within the rectum and anus. They develop from chronic constipation, straining and prolonged sitting (for those bathroom readers!). How do you know if you have them? They may present as some bleeding that is usually painless, anal irritation or itching or the painful lump in your anus that you can feel when you wipe after going to the bathroom.
As for the itching that you have, I'd be more inclined to believe it's related to your fissure than anything else. There is some, and I mean some, clinical evidence that points to certain foods – coffee, tea, soda, chocolate and some citrus fruits. I'd have to side with you since I would be unwilling to give up tea and chocolate! But I still have a feeling that your itching is due to something else.
Since I haven't seen you in person, it's always difficult to properly diagnose the case in a letter. But with all the information I have so far, I'd have to guess that you might have a complication from an anal fissure; in this case, a fistula – a small passage from the rectum/anus to the skin. Patients with these types of fistulas have chronic drainage in the area around the anus, some pain during bowel movements and skin that is itchy and irritated. In most cases, treatment is symptomatic – i.e. healing of the fissure with the treatments mentioned above. In other cases, treatment involves surgical intervention. The problem with this is fecal incontinence – depending on the position of the fistula.
What's my recommendation? As with any case in this column, I recommend consulting your primary care physician. The treatment options mentioned above could help with the fissure but the fistula may require further intervention. Just be forewarned that surgical treatment may cause fecal incontinence but only depending on the position of the fistula. If the position is good, however, then there is little risk of that complication.
Oh, and by the way, this condition has nothing to do with your age!
Thank you for writing. I hope you find this information useful. If you have any further questions, please feel free to write back!
