Doctors dealing with colorectal problems in their daily practice are well aware that patient’s pain is their greatest adversary. Pain may develop as a result of the underlying disease already before the patient presents to the doctor, but it can also be constant, occurring during therapy and after conservative, minimally invasive and surgical treatment.

We present a case report of a 54-year-old patient who presented to a colorectal outpatient clinic with severe anal pain. His medical history revealed alcohol dependence, at that time under treatment, with abstinence for about 6 months, as well as obesity (BMI 30), regular bowel movements, and colonoscopy 3 years earlier (sigmoid diverticula). He also had a history of posterior anal fissure surgery 6 years before. Despite intravenous NSAIDs and topical application of 2% lignocaine ointment, the patient did not consent for rectal examination. An initial diagnosis of an acute posterior anal fissure was made. Conservative treatment was started. Topical application of 2% lignocaine and 2% diltiazem ointment in the anal canal, oral metronidazole at 500 mg twice, stool softeners (Lactulosa, Fibraxine), probiotic (ProctoLact M), butyric acid, analgesics and anti-inflammatory drugs were included. Despite the treatment used, still no improvement was seen after 2 weeks. Rectal examination was not possible due to severe pain. The patient was qualified for examination under general anaesthesia, during which posterior recurrent anal fissure and oedematous, thrombosed internal haemorrhoidal columns were found. Inflammation of the rectal mucosa was excluded. A decision was made to continue conservative treatment. Salicylates were included. Despite some improvement after further 2 weeks, rectal examination without anaesthesia was still impossible. It should be noted that the patient had been advised to take NSAID analgesics and Tramal 50 mg before reporting for the examination.

After 12 weeks, the patient was qualified for a surgical procedure due to lack of improvement. The non-healing posterior fissure was excised under general anaesthesia. The specimen was sent for histopathological examination. Resorption of the thrombus in the haemorrhoidal columns was observed.