The primary pain comes from bowel movements, so this is where we will be begin.
The underlying cause of hemorrhoids is the lack of blood flow in the rectal area. The hemorrhoids sag and congest the rectal passageway, ultimately putting pressure on the anal sphincter, which tears open the anal fissure, causing blood and pain to surge into the area, which pools into the hemorrhoidal area and enlarges the piles further. It is a vicious cycle.
We must break this cycle. We can start this process by how we use the bathroom.
The goal is to spend as little time on the toilet. When we are using the bathroom, we must do everything we can to keep the blood in the rectal area circulating.
First things first: do not strain or push excessively when passing a bowel movement. This will merely cause more tearing and stress in the anal region.
Wait to Use the Toilet
You must wait until the bowel movement is nearly coming out on its own. It is tricky to get the timing right for this, but as long as you have a direct pathway to the toilet as you feel the bowel movement coming, you will be fine. The bowel movement should come out without effort and in one smooth move. See the chapter on eating for more information on how to make sure it comes out smoothly.
Squat, Don’t Sit
This will take some time as you have probably never squatted on a toilet before, and your muscles are not accustomed to it. As you get into the practice, it will get easier. Note how this leads back to the previous step – if you wait until you absolutely need to go, then you will not need to spend much time on the toilet squatting.
The idea behind the idea is that, by squatting, the blood below stays circulating. When you sit on the toilet, all the blood pools up into the seat area, and the pressure from sitting in the seat combined with the sedentary activity of the lower muscles causes stagnation in blood flow, which exacerbates the pain.
When you think about it, it is actually completely unnatural for us to sit while defecating. When you look at babies and toddlers, their natural inclination when pooping is to squat. We actually need to “train” them to use a toilet or potty, to go against what feels most natural.
It wasn’t until relatively recently that modern societies adopted the upright toilet. For a long time, many cultures had toilets that were built into the ground, and you had to squat to use them. I am reminded of the squatting toilet I had to use in rural France on a recent trip, or the many squatting toilets that are still commonly used in Asia.
Another key technique that will help reduce the pain: apply pressure to the fissure in the opposite direction while the bowel movement is coming out.
In most cases, the fissure is in the posterior side of the anus, which means it is in the back side. When you release a bowel movement, it forces the fissure to tear open by pressing in that direction. You can counter this by applying pressure with your fingers in the opposite direction, which will keep the fissure from tearing too much.
Take your fingers and push the area of skin just rear of the anus. I often find it is helpful to use a bit of toilet paper, as the area can get sweaty, due to the pain and duress your body is under. It is not dirty or smelly, it is merely just the area of skin outside the anus.
The technique is akin to applying pressure to a cut or wound, or squeezing together your skin after you get a cut so that you do not make the cut worse. It makes total sense when we do this after getting a cut – it keeps the wound from opening, allows the platelets to seal up the area quickly, reduces pain and aids the healing process. It is not any different with anal fissures.
Press Into Your Abdomen Along the Path of the Colon
Now, it must be said that not all bowel movements will pass in one fell swoop. They will also most likely be extremely painful. All the more reason to practice techniques to aid the passing of stool quickly and efficiently, without straining and pushing. This is especially helpful if you are experiencing any constipation.
In order to help move the stool along the gastrointestinal tract, apply pressure to your stomach area with your hands, outstretched fingers, and knuckles. You are essentially massaging the stool through the intestine and clearing out any blockages.
The large intestine pretty much runs the perimeter of the abdomen. It starts from the lower right side of the stomach, where the small intestine opens into the large intestine. It moves clockwise, up towards the right ribcage, across to the left ribcage, and then down the left side to the rectum.
There are two key areas to focus on when applying pressure and massaging the areas of the colon. The first is the upper left side, since this is where the stool must change direction and encounters the most resistance. The second area to apply pressure to is the lower right area, where the pathway of the large intestine begins. This will aid in moving the entire stool through the area, aiding your body’s natural peristaltic reflex.
Start by applying pressure with both hands from the upper left side of your abdomen. Use you fingertips or knuckles. Continue pressing down the entire left side, pushing into your gut. If you encounter any resistance or pain along the way, massage that area. Take deep breaths while you clear the pathway, exhaling sharply to release any tension.
When the left side feels clear and unblocked, press into the lower right area of your stomach. You may hear gurgling sounds, or feel matter moving through your bowels. Keep massaging any areas of tension and work your way up.
Press into the upper middle part of your abdomen. Continue to press into various areas of the stomach and work your way down until you feel you have expelled everything in your bowels.
When to Start Wiping
It is important to know when your bowel movement is actually finished. When you start your bowel movement, all the rectal tissue moves down and out. You will know when your body is finished when you will feel everything recede back in. This is when you should start wiping.
If you wipe before your body is actually finished, you will feel like everything down there is still hanging out and drooping down. Let your body finish the cycle by pulling all the tissue back in.
If you are under the duress of pain from anal fissure, it is most likely that this receding of tissue will be extremely painful. It is a natural Kegel movement, and this is something we will focus on later regarding practices that accelerate healing.
We have detailed how to have the quickest, most efficient bowel movement that promotes blood circulation to the area. Now let’s touch on various aspects of what happens after the stool has passed. The actual anal area is incredibly sensitive since this is where the fissure is. You do not want to exacerbate the pain by wiping aggressively.
When wiping, wipe towards the direction of where the fissure is. In most cases, the fissure is in the back side, so you will want to wipe from front to back. This means wiping starting from the perineum (the end of the anus that is closest to the penis or vagina) towards your back.
More importantly, we do not want any remaining residue or tissue to irritate the area. It is imperative to keep the anal area clean after passing any bowel movement, or else you may feel further pain or itchiness down there.
If at all possible, try to rinse the anus under running water. This may mean squatting down in your bathtub as you run warm water behind your back and rinse the area with your hand (again, from front to back). It is not the most convenient activity, but it is an incredibly useful, sanitary, and comforting practice. You will feel very clean afterwards and the action of cleaning and lightly massaging the area will allow the blood to circulate through the area. Of course, if massaging the area causes you any pain, just run water over the area and make the minimal amount of contact with your hand to clean it.
I understand that this may be difficult or impossible to do if you are in a public restroom or at work, so all the more reason to make sure to pass your bowel movement in the morning, in the comfort of your own home. We will go into further ways to ensure that you defecate in the morning later in the book.
I know it is widely recommended to take sitz baths, and if you do take sitz baths, this would be a great time to clean the area.
When I was going through the pain of anal fissure and trying all sorts of methods to battle the pain, I took multiple sitz baths every day – two to three times, in fact. I did it anytime I passed stool, when I got home from work, and before going to bed. I don’t think there is any harm in doing this, and it is helpful, especially when you are submerged in the sitz bath. But I can legitimately say that after having practiced this for over six months, sitz baths alone do not make the pain go away, at least in my case. I think for milder cases of hemorrhoids or anal fissure this might cure the symptoms, but for anything that is more chronic and severe, you will need to practice the other methods in this book.
Lastly, after washing the area and lightly massaging it, you want to make sure that the area is completely dry before you put any clothes on again. Having any moisture in the anal area can cause more irritation and stimulate harmful bacterial growth.
After you finish washing, dry your outer skin and buttocks with a towel, squat down, and then pat your anus dry with a piece of toilet paper. When you do your initial pat, it is very easy for some of the toilet paper to rip off and stick to your anal tissue. Make sure that the first pat is very slight – just enough to pull some moisture out of the way. Any wipes thereafter can be more thorough, since they will not run the same risk of sticking to your anus as you pat the area dry.