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United Kingdom, some surgeons in this country prefer it to a sphincterotomy. In essence, the surgeon stretches your tight sphincter until it partially tears. Most surgeons frown on this method because tearing occurs in an uncontrolled manner. With a sphincterotomy, the surgeon knows exactly how much muscle is cut. In theory, an anal dilatation should result in a higher incidence of postoperative incontinence, but that hasn’t been shown to be the case. If a surgeon recommends an anal dilatation, it may be that in
his
hands this is the best way to treat your problem. Surgeons are best at doing the type of surgery they have experience in.
    Gay men who practice anoreceptive intercourse may develop an acute fissure from direct injury. If treated with stool softeners and abstinence, this type of fissure should heal. If, however, a chronic fissure develops and surgery is required, then a sphincterotomy or anal dilatation is usually not necessary. Most often men who have had anal intercourse have already stretched their sphincter (I’m sure you can figure out how) and spasm is rarely present. The fissure usually will heal if the surgeon removes the scar tissue and closes the tear with a few stitches. Keep this in mind if a surgeon tells you a sphincterotomy is necessary. In this instance, you might be placing yourself at a higher risk for incontinence because your sphincter is already loose. You can always go back for a sphincterotomy if your fissure doesn’t heal after simple closure.
    HIV-positive patients often present with many different types of anal fissures that are atypical and quite complicated. HIV and medications used to treat it may cause diarrhea and subsequent fissure formation. The constant wet stool macerates the anal lining and promotes breakdown and tearing. (Think of your mushy skin after you’ve soaked in a tub for too long. ) Bulk agents and medications that control diarrhea (Imodium) often will cure this type of fissure.
    Although many times rectal bleeding and pain are the hallmark symptoms of HIV-related fissures, you may notice only a chronic purulent (infected) discharge and foul odor. Your discharge may appear as a brownish-green stain in your underwear. This type of HIV-related fissure looks different from typical anal fissures and more closely resembles a broad, shallow ulcer rather than a simple cut. As with any new symptom, if you have pain and an infected discharge, tell your physician.
    If you have HIV and a fissure, first treat it with topical steroid creams, stool softeners, and bulk agents. If healing does not occur, as is often the case, then the ulcer may need to be biopsied and removed. In these instances, your ulcer may result from many different HIV-related causes, including the HIV virus itself, tuberculosis, CMV, herpes, fungus infection, syphilis, lymphoma, Kaposi’s sarcoma, or other cancers.
    I
saw a young HIV-positive man whose fissures had been treated with creams and suppositories for two years by another doctor. He gripped the table prepared for pain as I slid my finger into his anus.
    I apologized for hurting him, but he said, “It’ll be worth it if you can just help me.”
    My heart sank. I felt his fissure, and I also felt the cancer that caused it.
    As a gay man with HIV, you may find yourself faced with a chronic, debilitating anal ulcer and a surgeon who refuses to operate on you. Oftentimes the medical community cites poor healing in HIV-positive patients as a reason for not treating their ulcers. Although this may be the case, if your immune status is relatively good, you should heal after surgery. Whenever faced with a physician who says “Sorry, but you’ll have to live with it,” get another opinion. You’ll probably find someone who’ll help you. I caution you, however, not to be too optimistic. Many times, even though your ulcer is removed and studied under a microscope, no cause for it is ever identified. However, simple removal may be enough to cure it. Of