What is the next treatment for my rectal pain and bleeding?

Question

Hello doctor,

I have been experiencing rectal bleeding and pain for the past two weeks, especially during bowel movements, although my stools have remained soft. About a week ago, I started using GTN ointment, but I have not noticed any relief. Two days ago, I took Flagyl, after which I did not have a bowel movement for a couple of days. However, today I experienced significant rectal pain again. When I checked, I could feel stool present, but there was considerable pain. I took another dose of Flagyl today, but I am still having substantial bleeding and pain. I have also done sitz baths twice.

Could you please advise on the next steps or further treatment I should consider?

Please help.

Thank you for your time and help.

Answer 1

Hello,

Welcome back to icliniq.com

I completely understand your concerns.

Thank you for sharing your concerns.

Rectal pain and bleeding can understandably be worrying. Based on the symptoms you described, pain during bowel movements, bright red bleeding, and soft stools, the most likely cause is an acute anal fissure.

Nitroglycerin (GTN) ointment often takes around 14 to 21 days to show significant improvement.
Metronidazole is generally not recommended for anal fissures unless there is a confirmed infection.
Constipation or stool retention can worsen pain and bleeding, even if the stool remains soft.

At this stage, investigations are usually not required initially. However, if the bleeding continues for more than 4 weeks, the following tests may be considered:

Proctoscopy (examine the rectum and lower anus using a small tube-like instrument to help identify causes of pain, bleeding, or other abnormalities)
Complete blood count (CBC)

The probable diagnosis is an acute anal fissure.

The recommended treatment plan should include the following:

Discontinue unnecessary antibiotics unless there are signs of infection.
Continue applying GTN ointment twice daily for six to eight weeks as prescribed.
For pain relief, consider taking paracetamol, or if your doctor advises, a local anesthetic ointment.

Stool Regulation by using a stool softener such as lactulose if recommended:

Follow a high-fiber diet including fruits and vegetables.
Drink two to three liters of water daily.
Avoid straining during bowel movements.
Take warm water sitz baths for 15 to 20 minutes, especially after bowel movements, as they can help reduce pain and promote healing.

Get medical help right away if you experience fever, heavy bleeding that doesn't stop, swelling around the anus is getting worse, or stools that are black or tarry

Please see a doctor again if your symptoms don't go away or get worse despite these steps.

I hope this addresses your concerns.

Please feel free to follow up if you need any additional clarification.

Thank you.