Anal fissure can be a pain in the butt!

The Goddess in Catalonia Square, Barcelona, Spain. (Dr. Noorali Bharwani)
The Goddess in Catalonia Square, Barcelona, Spain. (Dr. Noorali Bharwani)

Anal fissure is a painful and annoying problem. I have written about this twice in the last few years (2004 and 2014). These columns are posted on my website. I thought it is about time to review the subject again.

An anal fissure is a tear in the lining of the anus (anal mucosa). Most often it is caused by injury sustained during passage of a large hard bowel movement. Pain in the butt may be mild to severe. It may be acute or chronic (recurrent). Sometimes pain is associated with bleeding.

Other causes of anal fissure are: chronic diarrhea, anal intercourse and childbirth. There are other less common causes of anal fissures. These are: Crohn’s disease or another inflammatory bowel disease, anal cancer, HIV, tuberculosis and syphilis.

Fissures of less than six to eight weeks’ duration are acute, and those persisting longer are chronic. Chronic fissures are associated with skin tags at the edge of anal margin.

Anal fissures are very common in young infants but can affect people of any age. Most anal fissures get better with simple treatments, such as increased fiber intake or sitz baths. Some people with anal fissures may need medication or, occasionally, surgery.

Ninety per cent of fissures are located in the upper or lower anal midline. Fissures that are not in the midline (atypical locations) may be associated with cancer, Crohn’s disease, HIV, syphilis or tuberculosis.

Good news is most fissures will resolve with medical management.

Studies have shown up to 87 per cent of acute fissures treated with a high-fibre diet or stool-bulking agents (psyllium) and sitz baths twice daily will resolve the problem. Patients with chronic fissures require the addition of topical smooth muscle relaxants (two per cent diltiazem). Medical management will heal chronic fissures in 65 to 95 per cent of patients.

There is strong evidence that topical calcium channel blockers (diltiazem) have fewer adverse effects and similar fissure healing rates when compared with topical nitrates (0.2 per cent nitroglycerin ointment). More patients complain about headache with nitrates than diltiazem.

Diltiazem works by relaxing the muscle around the anus (the anal sphincter). This reduces pressure and increases blood flow to the area to allow healing to occur. About 30 per cent of patients will have recurrence of fissure after medical therapy.

Certain fissures may heal quite quickly, whereas others can take several months to heal. Patients whose fissures do not resolve after six to eight weeks of medical management should be considered for botulinum toxin injection or surgical management.

Even with classic symptoms and a midline fissure, patients with new rectal bleeding who are older than 50-years or have any suspicious symptoms (weight loss, change in bowel habits, unexplained anemia or family history of colon cancer) require colonoscopy to rule out a more proximal cause of bleeding.

Some individuals will need surgery. Most effective surgical procedure is called partial lateral internal sphincterotomy (division of anal sphincter). Most people will notice that the pain from an anal fissure goes away within a few days after the surgery. In my experience most people find immediate relief after surgery. Rarely a small number of people have problems controlling stools when they pass gas. This usually gets better with time.

Surgical treatment is offered to those who do not respond to medical treatment or who have frequent recurrences. Rate of recurrence of fissure after surgery is small, about three per cent in one study.

How can I prevent getting a fissure in the future?

The quality and quantity of stool passing through the anal sphincter is important. It should be soft, bulky and dry. Chew your food well. Eat lots of fruits and vegetables. Use psyllium daily. And relax when you have a bowel movement.

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Gluten Free Diet

Golden Gate Bridge, San Francisco. (Dr. Noorali Bharwani)
Golden Gate Bridge, San Francisco. (Dr. Noorali Bharwani)

Celiac disease is a serious autoimmune condition that occurs in genetically predisposed people where the ingestion of gluten leads to damage in the small intestine.

Celiac disease and non-celiac gluten allergy should not be taken lightly.

Celiac disease is a common lifelong intestinal disorder and runs in families. A first-degree relative with celiac disease has a 10-fold increased risk of acquiring the condition.

It affects about one in 100 people. A person can be critically ill to being completely well.

The risk is increased among people with autoimmune thyroid disease (three to five per cent), type one diabetes mellitus (five to 10 per cent) and Down syndrome (5.5 per cent).

Patients with celiac disease can present with a variety of symptoms. The classical symptoms include chronic diarrhea, abdominal pain, malabsorption and weight loss.

When gluten is ingested, it causes immunologically toxic reaction in the lining of the small intestine. The toxic reaction damages the lining of the intestine thus interfering with the absorption of nutrients and leading to diarrhea and malnutrition.

How to diagnose celiac disease?

The most widely available test is the tissue transglutaminase IgA antibody test, which has an estimated 95 per cent accuracy rate. If antibody testing is negative and celiac disease is suspected, the IgA level should be measured. All adults with an abnormal screening result should undergo a small-bowel biopsy to confirm the diagnosis of celiac disease.

Celiac Disease Foundation website says first-degree relatives of people with celiac disease – parents, siblings and children should be screened.

What is non-celiac gluten sensitivity?

The term non-celiac gluten sensitivity is used to describe the clinical state of individuals who develop symptoms when they consume gluten-containing foods and feel better on a gluten-free diet but do not have celiac disease.

Research estimates that 18 million Americans have non-celiac gluten sensitivity. That’s six times the number of Americans who have celiac disease. More research is needed to understand this problem.

Besides being sensitive to gluten often these individuals experience headaches, rashes and fatigue. These individuals have no inflammation or damage to the intestinal lining as in celiac disease.

Treatment is lifelong adherence to a gluten-free diet. The follow-up is most often provided on an annual basis, and includes reinforcement of the need to adhere to a gluten-free diet, dietary review, physical examination, laboratory tests and a recommendation to join a patient support and advocacy group.


The long-term prognosis for celiac disease is good as long as people with celiac disease follow a gluten-free diet.

Eating out is not always easy. Sometimes, no matter how prepared and informed you are, there is not a satisfying gluten-free choice. There are two strategies to address this. The first is to eat at home prior to dining out so that your hunger is under control and you are less tempted to make unsafe menu choices. The second is to bring gluten-free foods with you such as bread, crackers or even pasta, which you can ask the chef to cook in a clean pot.

Life is not easy for people with celiac disease or non-celiac gluten allergy. Patience and perseverance with dietary choices is the key to good health.

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Erectile dysfunction can be a sign of heart disease.

Cordoba, Spain. (Dr. Noorali Bharwani)
Cordoba, Spain. (Dr. Noorali Bharwani)

From time to time most men will have problems with erection. That isn’t necessarily a cause for concern. But some men have erectile dysfunction (ED). This is when it is difficult to get or keep an erection that is firm enough for sexual intercourse.

If ED is an ongoing issue then it will cause stress, affect your self-confidence and contribute to relationship problems.

ED can also be a sign of an underlying health condition like heart disease that needs treatment.

Recently, I came across an article in Choosing Wisely (2018 article developed in cooperation with the American Urological Association) titled “Testosterone for Erection Problems When you need testosterone treatment – and when you don’t.” Here is some information from that article.

What is testosterone and does it help men with ED?

Testosterone is a male sex hormone. After age 50, men’s levels of testosterone slowly go down and ED becomes more common. But unless you have other symptoms of low testosterone, you should think twice about the treatment. Testosterone treatment usually isn’t helpful for ED irrespective of your testosterone level.

Male sexual arousal is a complex process that involves the brain, hormones, emotions, nerves, muscles and blood vessels. ED can result from a problem with any of these.

Choosing Wisely says ED is almost always caused by low blood flow to the penis. This is a result of other conditions, such as hardening of the arteries, high blood pressure, and high cholesterol level. These conditions narrow the blood vessels and reduce blood flow to the penis. Low testosterone may affect the desire for sex, but it rarely causes ED. Stress and mental health concerns can cause ED.

Testosterone replacement therapy has many risks. Do not use testosterone without medical advice.

Erectile dysfunction: A sign of heart disease?

It is important to remember that the same process that causes heart disease may also cause ED, only earlier. ED can be an early warning sign of current or future heart problems.

From a purely mechanical perspective, an erection is a hydraulic event – extra blood must be delivered to the penis, kept there for a while, then drained away. An erection may not happen if something interferes with blood flow to the penis.

ED does not always indicate an underlying heart problem. However, research suggests that men with ED who have no obvious cause, such as trauma, and who have no symptoms of heart problems should be screened for heart disease before starting any treatment. Getting the right treatment for your heart might help with ED.

Fortunately, there are several ways to combat erectile dysfunction. Simple lifestyle changes like losing weight, exercising more, or stopping smoking can help. Drink alcohol only in moderation or not at all.

Further tests or treatment might be needed if you have more-serious signs and symptoms of heart disease. If you take certain heart medications, especially nitrates, it is not safe to use many of the medications used to treat erectile dysfunction.

ED is a complex medical problem. Get appropriate medical advice before you try any medications.

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What can we learn about our heart from a cardiac stress test?

Upper Kananaskis Lake, Alberta, Canada. (Dr. Noorali Bharwani)
Upper Kananaskis Lake, Alberta, Canada. (Dr. Noorali Bharwani)

Let us start by understanding the difference between cardiac stress test and cardiac Holter monitor.

What is cardiac stress test?

Robert Arthur Bruce (1916-2004) was an American cardiologist who invented the treadmill cardiac stress test used to diagnose heart disease. Patient’s heart signals are monitored on a treadmill set at successive stages of difficulty. Bruce also created the Bruce Protocol in the early 1960s, monitoring the heart signals of a patient on a treadmill.

Why is cardiac stress test important? Some heart problems only appear when your heart needs to work harder. Cardiac stress test helps to show how your heart copes under stress.

A cardiac stress test is done in a controlled clinical environment. It measures the heart’s ability to respond to external stress.  The stress response is induced by exercise or by intravenous injection of a medication.

What is cardiac Holter monitor?

Norman “Jeff” Holter (1914 – 1983) was an American biophysicist who invented the Holter monitor, a portable device for continuously monitoring the electrical activity (ECG) of the heart for 24 hours or more. Holter donated the rights to his invention to medicine.

The test is used to identify any heart rhythm problems. The device is the size of a small camera. It has wires with silver dollar-sized electrodes that attach to your skin.

Who needs cardiac stress test?

Any person who has a worrisome symptom like chest pain – especially in older men with risk factors for heart disease. An exercise stress test is not 100 per cent accurate. But it helps decide what the next step should be.

When to get a cardiac stress test?

The U.S. Preventive Services Task Force, an independent panel that makes recommendations to doctors, urges physicians not to routinely offer exercise stress testing to people without symptoms or strong risk factors for coronary artery disease.

Main indication for ordering stress test is when a person complaints of chest pain. Chest pain is not an uncommon complaint. Chest pain can have many possible causes besides heart disease.

For example, chest pain can be due to indigestion, anxiety, or muscle injury. If your doctor finds that you probably don’t have a heart problem, you may not need a stress test at all, says Choosing Wisely (2017 Consumer Reports. Developed in cooperation with the American Society of Nuclear Cardiology).

If you do have a heart problem, your first choice should often be a simple stress test without imaging. This test has little risk and is inexpensive. It is usually accurate for people with a low risk of heart problems.

Imaging stress tests are usually safe and can use little or no radiation. But for people at low risk, the tests may produce false alarms. This can lead to follow-up tests that you don’t really need. The extra tests can expose you to more radiation. Inappropriate testing can also lead to unnecessary treatment, says Choosing Wisely.

An imaging stress test can cost 10 times more than a regular stress test. You should only get an imaging stress test when it will help your doctor manage your disease or lead you to a better treatment. Discuss your symptoms with your family doctor. We can learn a lot from cardiac stress test if appropriately ordered.

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