TLDR

1. Pain with bowel motions is never normal. There is almost always a medical cause. You should see a doctor.

2. Anal fissures are the most common cause of pain while pooping amongst working age adults

3. Anal fissures are a two part problem - initial damage to the anal skin, and muscle spasm causing reduced blood flow and preventing healing of the original damage

4. To treat fissures, you need to prevent further damage to the anal skin by regulating your bowels. Your doctor can help treat the muscle spasm by creams, botox injections or surgery to heal the damage. Once the damage is healed, your pain will go away.

Why does it hurt when I poop, and what should I do?

Pain with pooping is never normal. Almost always it suggests that there is damaged skin somewhere near your anus. It is tricky to figure out what has caused the damage, and you will almost always want a professional to examine your bottom and figure out what is going on.

The 3 main causes your doctor will want to differentiate between are:

• Anal Fissures

• Thrombosed haemorrhoids

• Excoriated Skin

How do I know if I have an anal fissure?

It can be tricky to self diagnose, as it is hard to see the area. The usual symptoms are bright red blood on wiping, and a razor blade type pain when you use your bowels. Because there is an overlap in symptoms with haemorrhoids, there is often confusion between the two.

Here is an image (source)

As you can see, it’s pretty subtle, and if you don’t know what you’re looking for, you’re likely to call it the wrong thing. To make the diagnosis for certain, you should see your doctor. In general the younger you are (teens and 20’s), the more likely you are to have a fissure not haemorrhoids as a cause of pain and bleeding from the butt.

What causes anal fissures?

There are 2 important parts to an anal fissure - the initial injury, and the muscle spasm that prevents healing.

In short, fissures are breaks in the lining of the anal canal caused by trauma of some kind. Typically this is a constipated hard stool, but could also be explosive diarrhoea, anal sex or surgery to the anal canal like having haemorrhoids removed.

The butt is a sensitive area, so a small injury like a fissure can cause a lot of pain. One of the body’s natural reflex responses to pain is muscle spasm. For example, if you injure your back, the body responds with muscle spasm to keep the tissues stiff and still, and let it heal. In anal fissures, it’s the internal anal sphincter that spasms.

The butt is a sensitive area, so a small injury like a fissure causes a lot of pain. As a result the spasm is often intense.

Spasm is the reason fissures don’t heal, because blood flow to the area becomes reduced. This perpetuates the pain-spasm cycle.

Doctors have learnt (by trial and error) that relieving spasm is the best way to heal fissures. It is important to remember that the spasm is a reflex and not under your conscious control. Whilst many fissures do heal by themselves in the early stages, once the pain-spasm cycle is firmly established, anti spasm treatment is required to heal the fissure. Fissures lasting beyond six weeks are less likely to heal without treatment.

How are fissures treated? All of the effective fissure treatments work by relieving spasm. The only difference between them is how long the anti spasm effect lasts for.

As a starting point, regulating bowel function into the Goldilocks zone of passing a single, formed, play dough consistency stool is best. For most Westerners this means taking a fibre supplement of some kind like psyllium.

Treatments:

The commonest treatments for fissures are creams, Botox and surgery.

How do creams work? These creams contain medications that relax the anal sphincter muscle, restoring blood flow and allowing the fissure to heal. Typically these creams last six or eight hours and when used regularly will heal ⅔ of fissures in six weeks. The downside is the side effects.

Rectogesic is a prescription-only, “off-the-shelf” cream that contains GTN (Glyceryl Trinitrate), a medication traditionally used for angina (heart pain) and hypertension (high blood pressure). It works by relaxing the involuntary continence muscle (the internal anal sphincter). Unfortunately, because it is absorbed into the body, it can cause a throbbing headache as well as dizziness when standing up (postural hypotension) as side effects.

Diltiazem and nifedipine are re-purposed blood pressure medications and also work by reducing spasm, but by a different mechanism. They don’t cause headache, so are likely more effective because they are more likely to be consistently used. The downside is that these medications are not available “off-the-shelf” and therefore harder to source and obtain. In Australia, you need to get a compounding pharmacy to make it up. This means there can be differences from batch to batch, and different pharmacies might use different additives which may affect the effectiveness of the medication.

Botox injections (yes the same that are used for wrinkle treatment) are used because the botulinum toxin causes muscle paralysis and again reduces spasm. A small dose of botox is injected into the internal anal sphincter. Only a little bit of the sphincter has to relax, to improve the blood flow enough to heal the fissure. The advantage is that the effect lasts for up to 12 weeks. The downside is the injections are expensive, and at the moment must be administered by needle, often requiring hospital admission with anaesthetic, which further increases the wait times and cost of treatment. Effectiveness for one injection is said to be around 75%.

Surgery has the advantage of being 99% effective, but requires an anaesthetic, and the effect is permanent. The procedure is usually called a ‘lateral internal sphincterotomy’ and this involves cutting part of the continence muscle (usually about 5mm worth). The side effect is a theoretical increase in incontinence especially with age. In practice, because of the differing anatomy in males and females, it is used as a good option for resistant fissures in males. Males usually have a 30-35mm continence muscle, so cutting 5mm rarely causes long term problems. In females however, the muscle is shorter (25mm) and the effect of childbirth and menopause can reduce continence. It is therefore offered sparingly in females, because the rate of continence problems is so high anyway.

**The promotional bit.

**At downthere.healthcare we have a mission. We want to educate people as best we can about the common conditions affecting the penises, vaginas and butts, to the best of our ability. Science based, but also admitting where the science doesn’t exist.

We want to liberate the people with conditions that have previously been swept under the rug. They are common! We are all born with butts, penises and vaginas, or combinations of and use them in different ways, any they are subject to conditions and illnesses just like anywhere else in the body. You shouldn’t feel embarrassed to talk about it. If you want to do your bit to help us de-stigmatise these conditions, share our brand on your socials.

We also want to listen. In medicine there is a concept called ‘Level IV’ evidence, which says that in the absence of a rigorous scientific experiments, the next best thing is expert opinion. We disagree! Listening to lots of other peoples’ experiences is often more useful than listening to the opinion of a single expert, and we’d like to listen to, and share your experiences, opinions and complaints to make a difference.

With that in mind, for anal fissure, we are working on a few projects under the name “***Fiss Off”, and if you like what you see, we’d love it if you could show your support.

***Fiss Off Cream is going to be a cream containing:

• Diltiazem, which based on the existing scientific literature, has the lowest risk of side effects compared to the alternatives GTN and nifedipine, but equal effectiveness.

• Amethocaine - a smooth muscle relaxing local anaesthetic that both helps with the pain of fissures, but also (we think) will cause further sphincter relaxation, and improve healing.

We would like to do the necessary research to prove that this combination of medications is superior to the existing options “off-the-shelf” and get this approved by the relevant regulatory agencies. If you’re interested in helping out in some way, we would welcome that.

***Fiss Off Injectors will be a needleless botox injector using the principle of jet injection that will allow the botox treatment of anal fissures without needles or anaesthesia.

If you want to be updated on the progress of these projects, subscribe to updates on our website.

We welcome your feedback/support at contact [at] downthere.healthcare

Step 1: Break the itch-scratch cycle. This is the single most important treatment and may be enough to cure your itching
Step 2: If this fails, see a doctor. You may need treatment for a medical cause of itching Step 3: Identify and eliminate triggers. Optimise bowel function and toileting behaviour. Minimise lotions, potions, soaps and medications
Step 4: Keep skin cool, dry and protected to prevent recurrence

For the longer version, read on.

Step 1: Gain an understanding of the reasons your butt is itchy. This is the single most important treatment.

Itchy butt is an incredibly frustrating condition to have and treat.

One in twenty adults will have anal itching in their lifetime, with many suffering for years.

There is very little high quality information available to sufferers.

Let’s face it, it isn’t glamorous, and no one dies of the condition. Dermatologists who typically treat skin diseases are not inclined to look down there. The condition involves a junction of two organ systems (the gut and skin) meaning it’s kind of an orphan in the medical world. In addition, there is no magic bullet or simple script the doctor can give you that gets you out the door in time.

Understanding how the itching comes about and is triggered will help more than any medication your doctor can give you.

There are two important considerations. Eliminate medically treatable/important causes, and then find out what works for you.

Here is an example of what the condition typically looks like:

What can be seen here are features of the self perpetuating itch-scratch cycle. The fragile anal skin is irritated by some trigger (there are more than 150 triggers) and becomes inflamed and cracks, like a motor mechanic’s calloused hands. The cracked skin leaks moisture, which itches and irritates the skin further, leading to further scratching. The long term irritation and scratching cause the skin to thicken as a protective mechanism, which leads to further cracking.

The self perpetuating cycle then goes around and around, often for years.

In the photo, you can see the typical shield shaped area (this is the area where the buttocks are opposed when standing, leading to moisture) with central whiter skin which is abnormally thickened, and surrounded by red (inflamed) skin with ulcers. Now that we know what it looks like, and that it is common, let's talk about the next steps above in more detail to break the itch-scratch cycle.

Step 2: Treat common underlying causes Whilst a large number of patients have an itchy bottom all the time, without an easily identified cause, there are a number of known medical conditions that need to be thought about.

• Bowel cancer. This does not commonly cause itching, but in many countries is the second or third most common cause of cancer death. If you have a bowel or anal problem of any kind, it’s important to have a colonoscopy if you are over the age of 45.

• Haemorrhoids. Anything that contributes to moisture around the butt can worsen itching. The type of haemorrhoids that feel like a lump popping in and out of the butt and are best treated by your doctor to reduced moisture around the butt skin.

• Worms. If you have young children, or anyone in the family who has had worms, taking a simple deworming tablet is worthwhile.

• Fungal infections. If you have, of have had fungal nail, foot or groin infections in the past, a trial of a tablet anti-fungal tablet is worthwhile.

• Skin conditions like psoriasis. This is usually obvious as there are further areas of skin around the body affected. These should be treated by your dermatologist.

Step 3: Optimise bowel function and toileting behaviour. Consider bowel function like a driving style, and the butt like the tyres on your car. If the driving style is all over the place, the tyres are going to wear out faster.

Suboptimal poop type, especially those which are too loose or pasty are going to contribute to skin problems around the butt, as any parent who has had a kid with a nappy rash will attest.

Faeces is highly irritant to the skin. It may be related to the acidity/alkaline nature, or just the moisture content. In any event, any person with an itchy butt needs to optimise bowel function. The rectum and butt are designed to deal with a play dough like stool best.

If you have an irritable bowel, see a dietician to remove the triggers for loose bowel movements. Even if you have the best diet possible, take a fibre supplement like psyllium or flax seed.

Conventional toilet paper is an odd western convention, pushed by marketing. The worst outcome for an itching butt is to be subjected to several loose bowel movements daily, cleaned up by rough toilet paper, likely leaving stool residue and moisture as well as sandpapered, irritated skin.

On the other hand, a single daily formed play dough like stool, followed by a water rinse and air dry is optimal. The Japanese do it best with rinsing toilet products like this or this. If you have an itchy butt and are renovating your bathroom, install one of these. There are cheaper versions too like this or this.

**Step 4: Minimise lotions, potions, soaps and medications **Having stressed the importance of keeping the skin around the butt clean, there is a problem in the other direction too, often labeled over-hygiene.

Many patients develop allergies, called ‘contact dermatitis’ to one of the chemical ingredients in soaps or washes available. Keep cleaning to using simple water only where possible.

Commonly prescribed medications are worth a special mention. Many are made with two common ingredients: local anaesthetic creams and steroid preparations. The local anaesthetic acts as a numbing agent, and the steroid acts as a powerful anti-inflammatory.

Local anaesthetic agents, recognised by the use of the letters ‘caine’ at the end (e.g. lignocaine, cinchocaine) cause a contact dermatitis with long term use, and steroid preparations, recognised by the use of the letters ‘sone’ at the end (hydrocortisone, betamethasone), thin the skin down, making it more fragile, and worsen the problem long term. Both of these ingredients are best used for less than two weeks, and if you are using for longer than 2 weeks, see your doctor for advice.

Step 5: Keep skin cool, dry and protected Skin itches when it is hot, moist and irritated. Many sufferers attest that itching is worse at night, after having had a shower (moisture) and getting under a warm duvet in bed (heat). For those in cold climates, if you are itching badly at night, go outside with no underwear and count the seconds until your symptoms disappear.

Cool, dry, protected skin does not itch. Hot, moist, irritated skin itches like crazy.

Consider the way the body registers itch. From the brain’s perspective, itching is classified as a form of low grade pain. It is carried along those dedicated pain nerve pathways, and medical science knows a lot about them.

Think about what we all do when we get an injection, stub our toe or hit our shin on the coffee table. We rub it like crazy. Or consider why a heat pack feels good for period pain, or why an ice pack is good for a sprained ankle. What is going on here?

This phenomenon is called counter-irritation. The nerve pathways are like telegraph poles and can only process sensation at a certain rate. Both pain and itch can be blocked by providing background noise.

The brain is a selective filtering machine, and this is what pickpockets exploit. Bump you on the right, steal your wallet from the left.

We can exploit this to block itching too. There are a limited number of known counter irritants, and these can be used to block itching. Deep heat and Tiger balm are good examples. The key with skin around the butt is that it is sensitive. Getting the level of background noise just right is the tricky part.

The promotional bit.
|At downthere.healthcare we have a mission. We want to educate people as best we can about the common conditions affecting the penises, vaginas and butts, to the best of our ability. Science based, but also admitting where the science doesn’t exist.

We want to liberate conditions that have previously been twittered about and swept under the rug. They are common! We are all born with butts, penises and vaginas, or combinations of and use them in different ways, any they are subject to conditions and illnesses just like anywhere else in the body.

We also want to listen. In medicine there is a concept called ‘Level IV’ evidence, which says that in the absence of a rigorous scientific experiments, the best evidence is expert opinion. We think that aggregated patient data is better, and we’d like to listen to your experiences, opinions and complaints to make a difference.

With that in mind, for the orphan condition ‘pruritus ani’ or itchy butt, we have created a treatment that works in the following ways.

Itchy butt contains: -a calibrated amount of camphor and peppermint oil aimed at providing just the right amount of counter-irritation to block itching signals without producing a burn. This produces a cooling menthol feeling. -skin protectants in the form of plant based waxes and zinc oxide to protect the skin from moisture and contamination-a base uniquely suited to the skin around the butt.

Itchy-butt contains no petrochemical based products, and we have listened to many pruritus ani suffers to get the exact combination right.

You can source at itchybutt.com

We welcome your feedback at contact [at] downthere.healthcare