1) Please get these tests: complete blood count with peripheral smear, serum ferritin and iron studies, vitamin B12, vitamin D, thyroid profile, blood sugar, ESR/CRP, urine routine, and an ultrasound of the abdomen and pelvis. In your case ferritin and the pelvic ultrasound are the two most important. 2) See a colorectal surgeon for one careful examination of the anal region (with examination under anaesthesia if it is too painful) to document whether there is a residual fissure, a stricture/stenosis or sphincter spasm - this decides treatment, and a 5th surgery is not the automatic answer. Many post-fissure pains respond to sphincter-relaxing ointment, stool softeners and pelvic floor physiotherapy/biofeedback. 3) See a gynaecologist too, since the pain radiating into both legs with the whole lower body aching needs the pelvis assessed. 4) Continue your sitz baths - they are safe and helpful. Keep stools soft with high fibre, 3 litres of water and isabgol at night. 5) Please start eating again, in small frequent meals with protein and iron-rich food; your weakness will not improve while intake is low. Iron and other supplements should be started on the basis of your reports. 6) The 20 kg weight loss and your low mood/energy also deserve attention - chronic pain at 21 with a job to hold down takes a real mental toll, and support for that is part of the treatment, not a weakness. Please carry all your previous operation notes and reports to the visit. I will gladly review everything with you on a Practo online consult, or you may consult me at Synergy Multispeciality Hospital, Miraj.

Please do not take repeated painkillers on your own or agree to another procedure before the above work-up. Go to a hospital immediately if you develop fever with chills, a hard painful swelling near the anus, heavy bleeding, inability to pass stool or urine, fainting, or severe continuous abdominal pain with vomiting.

Cap SOMPRAZ-L/OD BBF TAB MACROID 1000 mg Thrice a day for 4 days f/b twice a day for 5 days TAB GABANT NT 100 mg/HS P/W Livoluke RF FIBRE 2 tsf with lukewarm water/ HS Cream SITCOM FORTE LA/BD SITZ BATH WITH BITADINE THRICE A DAY ADEQUATE HYDRATION AND HIGH FIBRE DIET REVIEW AFTER 7 days

Your case sounds complex, and I’d be happy to guide you regarding the appropriate evaluation and treatment approach. If you want to discuss your symptoms in detail, you can connect with me on WA business- 77 260 46 121, I’ll take your complete history and guide you about the appropriate next step.

- Arrange an in-person review with a colorectal surgeon/proctologist. - Discuss your persistent pain, abdominal symptoms, 20 kg weight loss and weakness with the doctor. - Your doctor may consider blood tests such as CBC and iron studies to assess for anaemia/iron deficiency. - Depending on the examination, further gastrointestinal or pelvic investigations may be advised. - Avoid proceeding with another surgery until the cause of the persistent symptoms has been reassessed.

Continue adequate hydration, maintain a fibre-rich diet and avoid straining during bowel movements. Warm sitz baths may provide symptomatic relief if they are comfortable for you. Given the significant weight loss, increasing weakness and abdominal pain, please do not delay an in-person medical assessment. Seek urgent medical attention if you develop fever, increasing swelling or pus around the anus, severe worsening abdominal pain, heavy bleeding, vomiting, fainting or severe weakness.