Dear Dr. Roach: My husband has been diagnosed with a rectal fissure. It has been a couple of months, and it isn't any better. He has been treated only with a stool softener. What do you suggest?
A: Anal fissures are painful. Although a stool softener is one part of management for people who have constipation, additional treatments also are appropriate, including a sitz bath, which is just a few inches of warm water in a basin or tub that you soak your bottom in. When I was an intern, I wondered about the origin of the term "sitz bath." My resident, Dr. Lynn Brown, told me that it's because you "sitz" in them, and it turns out she was right: It's from the German "sitzen," meaning "to sit."
Other treatments include increased fiber and a topical painkiller (there are many over-the-counter preparations in ointment form). These treatments help heal the fissure by relieving anal spasms caused by a painful bowel movement. I'm afraid your husband hasn't had adequate treatment, leading to a vicious cycle of pain, spasm and nonhealing.
In addition to these treatments, fissures heal more quickly with a medication to increase blood flow to the area: Nitroglycerin is available as a prescription ointment, and nifedipine can be compounded for topical use by a pharmacist, with better healing and fewer side effects than nitroglycerin (but both of these work better than no treatment). If this isn't effective after a month, he should be re-evaluated. There are other options available before considering surgical treatment. A gastroenterologist is a good resource if his primary doctor hasn't been successful.
One other concern is that occasionally anal fissures are a sign of Crohn's disease, a serious inflammatory bowel disease. People with recurrent, atypical (not in the midline) or nonhealing fissures should be evaluated for Crohn's disease.
Dear Dr. Roach: You recently wrote about exercise causing rhabdomyolysis, and I have a question about that. My 92-year-old mother-in-law fell, and wasn't sure how long she laid there, but the doctors said she had no broken bones. However, she did develop rhabdomyolysis. Since she does not exercise, how did she acquire this condition? The only medication she is on is one for blood pressure.
A: Rhabdomyolysis is a very serious condition of muscle breakdown. The most common cause I have seen is your mother-in-law's: pressure on muscle in someone who is unconscious or unable to move for a prolonged period (in normal sleep, the body changes position frequently, which prevents this). However, it can happen in untrained people after heavy workouts, or even in trained athletes who do extreme workouts, especially in hot and humid conditions. Some medications rarely can cause it, such as colchicine or statin drugs. Rhabdomyolysis is treated conservatively, by removing the underlying cause, and trying to prevent damage to the kidney.
For elderly or frail people who live alone, I recommend a device that can be easily carried and pressed to get help. Some of these can recognize a fall and will send a signal automatically. Falls are common in the elderly, and these devices can help prevent some of the serious consequences of falling.
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Readers: The booklet on sodium, potassium chloride and bicarbonate explains the functions of these body chemicals and how low or high readings are corrected. To obtain a copy, write: Dr. Roach, Book No. 202, 628 Virginia Dr., Orlando, FL 32803. Enclose a check or money order (no cash) for $4.75 with the recipient's printed name and address. Please allow four weeks for delivery.