At some time or another, many people find a little blood in their stool, usually after a particularly hard bowel movement and can become confused and upset at such an event. At other times, alarmed individuals go to the doctor complaining of rectal pain after a bowel movement with no apparent blood in the stool. Often the doctor gives the diagnosis of anal fissure or hemorrhoid to these complaints. To most people this can sound foreboding. In fact an anal fissure is like a paper cut in the internal anal sphincter. Hemorrhoids constitute another condition that is painful and sometimes the source of blood in the stool. A hemorrhoid is a kind of varicose vein in the anus.
One French study showed that one third of women had hemorrhoids or anal fissures after childbirth. One to ten million people in North American suffers from hemorrhoids. Both of these conditions are common in both men and women. These conditions are often related to constipation and diarrhea. Constipation has been related to chronic tension in the pelvic muscles in adults and recently in a study at the Mayo Clinic in refractory constipation in children.
The colon and rectum are structures that operate together in the activity of the evacuation of stool. Normal, non constipative bowel function involves the reflex relaxation of the external anal sphincters the pelvic floor muscles (along with sufficient tone in the colon) to allow the reflex of the sense of urgency with the filling of the rectum for fecal matter in the bowel to pass through the anal canal. Chronic tension in the bowel and pelvic floor triggered by anxiety can commonly result in constipation.
It is understood by many of researchers that the anal fissure is what is called an ‘ischemic ulcer’. Ischemia is a condition in which there is a significant reduction in blood flow to an area. The current understanding about anal fissures is that because there is elevated tension, the blood flow in the anal sphincter is reduced thereby impairing the tissue which then becomes fragile and vulnerable to injury from a hard bowel movement or from the pressure of bearing down during defecation.
Diet has clearly been implicated in the development of the anal fissure. Cow milk consumption has been associated with chronic constipation and anal fissures in infants and children. Interestingly, a shorter duration of breastfeeding and early bottle feeding of cow’s milk are also suspected to play a role in early incidences of anal fissures in infants and young children.
A Danish study showed a significant relationship between the absence of raw fruits, vegetables and whole grains and anal fissures. Furthermore frequent consumption of white bread, sauces thickened with roux and bacon and sausages increased the risk of anal fissures. British researchers found that hemorrhoids and anal fissures were much more likely to occur when one did not eat breakfast.
While most anal fissures and hemorrhoids resolve themselves after they flare up, some colorectal surgeons lean toward a procedure or surgery to treat hemorrhoids and anal fissures. We have seen patients who are anxious about their rectal discomfort easily talked into an aggressive treatment of the fissure or hemorrhoid involving surgery.
It is generally agreed that the source of the anal fissure in large part involves a chronically tightened internal anal sphincter. Surgery, the procedure of stretching or dilating the anal sphincter under anesthesia, and the application of topical agents to the internal anal sphincter are all aimed at relaxing the anal sphincter. The concept of surgery for anal fissures is based on the peculiar idea that cutting the sphincter is the best way to reduce the tone, tension and spasm in the anal sphincter. While surgery is often successful, there is risk of short term and sometimes long term fecal incontinence.
This conventional medical treatment of anal fissures, hemorrhoids and constipation tends to ignore the relationship between mind and body. Like the conventional treatment of prostatitis, the relationship of a person’s mindset, level of relaxation during bowel movements, and management of stress is almost entirely ignored in the literature on the anal fissure. Instead, there is a narrow focus on immediately reducing symptoms of the anal sphincter, hemorrhoid or slow transit times involved in constipation. Procedures, surgery, laxatives and other medications are the usual options for patients suffering from these conditions. Like in the treatment of prostatitis, there is little literature on the connection or treatment of body and mind in the anal fissure, hemorrhoid or in problems of constipation.
The focus on a surgical intervention for the anal fissure or hemorrhoid is an expression of a viewpoint that sees no value and sees no intelligence in the symptoms someone with such a condition is experiencing. Instead of seeing the symptom of an anal fissure, for example, as the way in which one’s body is complaining of the diet, stress, bowel habits and anxiety one is under, conventional treatment sees the symptom of blood in the stool, rectal pain or abdominal pain as something that needs to be stopped. No regard is shown for the big picture of a person’s life and how one’s symptoms are a response to this big picture. As we have said elsewhere, it is our view that the symptom is the way our bodies are trying to communicate. If we simply try to refuse to understand the message because we don’t understand the body’s language, we needlessly suffer and don’t deal with the root problem prompting the symptom. We continue to suffer.
In the large majority of cases, it is the chronic tension in the pelvic floor, including the anal sphincter, usually combined with diet, and anxiety and time urgency around bowel habits that leads to anal fissures, hemorrhoids and constipation. The chronic pelvic tension, inappropriate diet, and bowel habits associated with most anal fissures, hemorrhoids and constipation do not come out of the blue. In a word, a person’s mind and body and lifestyle are involved in the creation and perpetuation of these conditions.
Squatting vs. sitting during defecation as way of helping the relaxation of the pelvic floor
Most people throughout history have squatted when they have evacuated their bowels. The modern toilet is relatively new in the history of mankind and has been adopted as a civilized bathroom appliance. The perennial hole in the ground over which one squatted to defecate is universally considered primitive. A website (www.naturesplatform.com) devoted to promoting the advantages of squatting during defecation writes about the history of the modern toilet:
“Human beings have always used the squatting position for elimination. Infants of every culture instinctively adopt this posture to relieve themselves. Although it may seem strange to someone who has spent his entire life deprived of the experience, this is the way the body was designed to function.
The modern chair-like toilet, on the other hand, is a relatively recent innovation. It first became popular in Western Europe less than two centuries ago, largely by coincidence. Invented in England by a cabinet maker and a plumber, neither of whom had any knowledge of physiology, it was installed in the first dwellings to use indoor plumbing. The “porcelain throne” was quickly imitated, as the sitting posture seemed more “dignified” – more suited to aristocrats than the method used by the natives in the colonies.
Two other influences also favored the adoption of this new water closet. One was the headlong rush to modernize all existing sanitation facilities (which were in fact non-existent.) The public assumed that all the benefits of modern plumbing required the use of the seat-like toilet, since it was the only one having the proper fittings to connect to the pipes. This assumption was incorrect, since toilets with all the same flushing capabilities could be (and have since been) designed to be used in the squatting position.
Secondly, in nineteenth-century Britain, any open discussion of this subject was considered most improper. Those who felt uncomfortable using a posture for evacuation that had nothing to do with human anatomy were forced to keep silent. How could they denounce the toilet used by Queen Victoria herself? (Hers was gold-plated.)
So, like the Emperor’s New Clothes, the water closet was tacitly accepted. The general discomfort felt by the population was indicated by the popularity of “squatting stools” sold in the famous Harrods of London. These footstools elevated one’s feet while in the sitting position to bring the knees closer to the chest – a crude attempt to imitate squatting.
The rest of Western Europe, as well as Australia and North America, did not want to appear less civilized than Great Britain, whose vast empire at the time made it the most powerful country on Earth. So, within a few decades, most of the industrialized world had adopted “The Emperor’s New Throne.”
A hundred and fifty years ago, no one could have predicted the effect of this change on the health of the population. But today, many physicians blame the modern commode for the high incidence of a number of serious diseases. Compared to the rest of the world, people in westernized countries have much higher rates of appendicitis, hemorrhoids, colon cancer, prostate cancer and inflammatory bowel disease.”
There is compelling evidence that sitting on the toilet to evacuate the bowels is inferior to squatting in a number of ways. Squatting tends to relax the puborectalis muscle which is essential in defecation. It tends to reduce or eliminate the need to strain and bear down to initiate defecation. A long study examining the effect of squatting during defecation and hemorrhoids showed improvement or elimination or hemorrhoids as the result of squatting during defecation. Doing the ‘valsalva maneuver’ in which one bears down to initiate defecation while holding one’s breath have been known to cause a fatal heart attack or sometimes episodes of atrial fibrillation because such a maneuver increases pressure in the thorax and interferes with venous blood returning to the heart. The heart rate can significantly drop during this activity. Defecating while squatting can reduce the need to bear down and set this cycle in motion.
The modern toilet makes squatting during defecation a little problematic as it is made for sitting. Nevertheless, with a little innovativeness, it is possible to squat on a toilet. On www.naturesplatform.com a device is sold that allows one to easily squat during defecation. When pelvic pain also involves anal fissures, hemorrhoids or constipation, the issue of integrating squatting during defecation might well be considered.
We would like to see research on a non-invasive and self administered treatment of both anal fissures and hemorrhoids and certain types of chronic constipation following our protocol for pelvic pain with some modifications. This would involve the rehabilitation of a very tight pelvic floor using Trigger Point Release, modifying the habit of tightening the pelvic muscles habitually under stress and during defecation and a focus on reducing anxiety producing thinking that prompts increased and habitual levels of anxiety. Squatting during defecation as described on www.naturesplatform.com should strongly be considered as part of the protocol. While there is little research done on the treatment of these kinds of conditions using this perspective, we strongly support an independent study evaluating the efficacy of a modified Stanford protocol for the treatment of anal fissures and hemorrhoids and certain kinds of constipation.