Brief Answer:
As discussed in details.

Detailed Answer:
Hi.
Thanks for your query and follow-up.
Read our discussions of the past and the history you have given just now
Noted that it is exactly 2 months finished, still have anal pain in the morning for
2 -4 hours after bowel movement varying from mild to strong, stool is smooth.
Wound is not yet completely healed, scar and pus present.

Let me answer your queries and discuss on the way:
1 is this normal to have anal pain even after two months after surgery
> No, this is not normal to have pain after 2 months of surgery and indicates that there is still some inflammation in the area near the anal canal which when dilated during passing motion causes this pain.

2. Is pus discharge normal
> Pus is a collection of the body fluids, dead or dying bacteria and tissues and indicate that the process of infection is still going on.

3 what I can do to fasten the healing process
> I would advise you the following things in such a situation:
- Review by your operative Surgeon or a second opinion of another Surgeon for clinical evaluation, examination, per-rectal examination, proctoscopy, colonoscopy and further investigations.
It is possible that the tract is not yet completely healed and proper investigations and proper management will hasten the process of healing.
- MRI of the area helps in a proper diagnosis and knowing the extent of healing and the remaining disease process.
- Revision of the histo-pathology report of the sample if was sent for the examination.
- Tests for hemoglobin and serum proteins. If less, supplements should be given to correct the deficiency if any.
- Multivitamins, Vitamins A and D in therapeutic dosages do help in better healing.
- Pus to be sent for gram staining, AFB staining, culture and sensitivity.
- Further medications as per the reports of various investigations and clinical evaluation.
- Ask your Surgeon if further refreshing or re-curettage or any process is required or not and if advised so, it is better to get this done, since it is 2 months already.

I hope this answer helps you further, please feel free to discuss, ask for further relevant queries if you feel that there is a gap of communication.
Please post the clear photographs of old or recent if possible.

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Brief Answer:
Let us know the present status.

Detailed Answer:
Thanks for your appreciation.
The one with a clear view in knee-elbow position is clear and classical of a fistula.
The last one is not clear, please post in both the position.

No, usually no complexities are produced so nothing to worry about any complications as such.
Please try for MRI, it helps/ Fistulogram to see whether this is low anal or high anal type.
The procedures for such cases are done in the same way all over world and the fistula are known to be notorious for recurrences and hence it may not be an important issue whether surgery is done there or in XXXXXXX
\But if you persist I will find the best one for you in XXXXXXX or so and the modality of treatment once we know for sure whether this is healing or not or whether there is recurrence or not.
Please get some of the investigations done and give me the reports so that I can help you the best.

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Brief Answer:
Granulation outgrowth, known to occur in such chronic wounds.

Detailed Answer:
Hi.
Thanks for your feedback and I could get that there was a granuloma that usually develops at the opening of such a chronic wound which was removed.
Reviewed all the attachments you have posted.
Please continue taking sitz bath before and after passing motion, helps in relaxing the sphincters.
In addition you can get multivitamins with Lycopene from the medical stores, continue these.
You can certainly take a painkiller with anti-inflammatory properties like Ibuprofen for the pain.
Let us wait and see.

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Brief Answer:
Try relaxation of sphincter

Detailed Answer:
Please feel free to ask any relevant question, I shall be happy to assist you, do not hesitate.
This granuloma or granulation is not related to the pain inside the anal canal, it never is.
The cause may be due to the following reasons:
Since the surgery of such a disease is bit extensive and the aim in infective pathology is to clear the disease, there is a lot dissection, cutting, clearing and so on. This exposes the muscles and nerves, some get cut, some get inflamed and then scarified, some muscles may go into spasm due to the process of pain itself or fear of pain, anxiety of what will happen and hence this process of stretching is repeated every time you pass the motion and hence the pain and its continuation for 2 to 4 hours indicate the reasons just mentioned here.

This is how the Sitz bath helps by soothing action.
Hence the anti-inflammatory medicines may help.
I have seen some good results with medicines like Amitriptylin or pregabalin which are used for neurological pain. ( but your Surgeon may not accept this if he has no experience in this regards). You may try a local/ family Doctor if you have this facility in the country you are staying in. (Which country are you in at the moment?)
You should learn to try to relax your anal sphincter purposefully first, when sitting in the toilet, not to rush through the process of defecation, and once achieved you may pass motion with less or no pain during or after defecation.
Take your time in the toilet. Do this and please let me know the results. Helps my many patients.

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