I went to a different CRS for a second opinion on Botox and got some contradicting advice on how to heal fissures.
CRS A: Take stool softeners and miralax to keep stool soft.
CRS B: Only take fiber or Metamucil and keep stool to Bristol 2(!) or 3 to avoid irritating fissure.

CRS A: Botox has similar healing rate as nifedipine. Fissure comes back anyway.
CRS B: Botox gives us 80% healing rates, and is a good option before surgery, can heal fissure.

CRS A: Surgery not a good option since fissure is in control.
CRS B: Take your pick of Botox or surgery.

Why do doctors have such varying opinions on how to treat fissures?

Because medicine like many other things isn't an exact science! ;) I find it quite useful to read articles published in peer reviewed academic journals but again people seldom agree even when you look at peer reviewed publications...

Hah, good luck getting a doctor to agree that their current opinion doesn't agree with the latest research. IMO the medical field is rather slow at getting new information across to doctors.

I've got a PhD and it can be quite handy at times to use that as 'leverage' when discussing things with MDs despite my field being far removed from medicine... :)

I suspect many MDs who don't work at teaching hospitals and are active researchers themselves are very slow at picking up the latest research.

Yes the teaching hospital doctors are usually up to date, but I just had a Stanford doc tell me she sees an 80% healing rate with Botox, while the other doc said the literature doesn't support that. You really can't predict these docs!

Please remind me, which creams/ointments have you used so far to try to heal the fissure?

80% healing rate is pretty good as far as I'm concerned. Then again the paper pinned at the top of the Anal Fissure board suggests that diltiazem etc have similar rates.

Is the Stanford doc the one you used for a second opinion or your first CRS?
I'll book an appointment with a CRS next week and he's in charge of the surgery division at one of the good UK research university hospitals. I've looked up some of his papers on Google Scholar and he seems good at both fissures and hemmies (as I have had them pop up, or shall I say out, too. Yuck!).

I hope you're doing okay.

I've used nitroglycerin and now on nifedipine. I can definitely feel the nifedipine reduce the tightness but it's not working well enough to heal things I guess. I also used ketanserin for a bit which helped some and I'm planning to start it again. I'm doing ok, some days better than others. Never imagined my daily life would be such a struggle.

The Stanford doc was my second opinion, and she seemed ok. Not as informative as the first doc.

Your doc sounds like a top guy. I hope you he takes good care of your case.

How are you doing now? Any luck with getting Botox?

I've got the appointment with the CRS on Monday. I hope he's as good in person as he looks on paper! I'll ask that he doesn't prod around but simply visually inspect as I'm still recovering from the hemorrhoid incident ten days ago.

I'm scheduled for Botox on the 15 th and I'm getting more nervous as the days go by. I'm worried about side effects from it even though the doctor said it should be fine. I'm sure it'll be painful too, and that's going to be difficult to manage as well.

Usually the doctors make sure not to insert anything like an anoscope. All they need to do is spread the cheeks to see the fissure, unless it's higher up. For me even that spreading caused more pain after the exam. So just be prepared that it may happen.

It's great that you've got the Botox scheduled for the 15th! Do they do it when you're fully awake or do they sedate you? You'll hopefully notice a major positive difference once it kicks in.

The GP last week just spread my cheeks to have a look and he spotted the fissure then. I wasn't particularly sore after that but it is uncomfortable when they're spread.