So I have been using Diltiazem for about 6 months now, twice a day usually at about 12 hour intervals and am totally dependent on it. I find that with exercise and masturbation/intercourse my fissure will be worse for a couple weeks before it gets any better. If I get an erection I am sure to have pain later on in the day, and being 22 years old this is very troubling.
My question is when should I stop using Diltiazem and opt for surgery? I don't have trouble with bms but I get sharp pinches throughout the day and this whole lifestyle just has me depressed. It's been over a year since I got my fissure and it is not healing. What should I do?!?!

Hey bro, have you considered trying something like Botox? I forget how long you've been using diltiazem, but if it's been a while, and your fissure has been there for a over a year, then honestly I'd say the odds of it healing using he current course of treatment are probably not that high...
Being reluctant about surgery is definitely understandable, but a lot of people try Botox as the step between the ointments and surgery. It definitely helped me for at least a few months, and a couple of members have healed completely from it.
If *ahem* sexual activity causes the fissure pain to get worse for weeks then that sounds pretty serious to me. When my fissure was really bad, such activity would cause me some discomfort but certainly not for weeks afterward.
I've personally had an interesting run with surgery so far so I'm not going to tell you to jump right into it, but I think given how long you've been dealing with this, I would seriously consider Botox as the next step.

I think I would try Botox.

I would go for a LIS - that is the only permanent solution.
Or maybe you can try a Botox and if that does not work or you have a relapse- than go for a LIS
Best of luck with anything you decide !!!

Comparison of surgical vs chemical sphincterotomy using botulinum toxin for the treatment of chronic anal fissure: a meta-analysis.
Sajid MS, Hunte S, Hippolyte S, Kiri VA, Maringe C, Baig MK.
Department of Colorectal Surgery, Worthing Hospital, Worthing, West Sussex, UK. [email protected]
Comment in:
Colorectal Dis. 2008 Jul;10(6):529-30.
Abstract
OBJECTIVE: To analyse systematically prospective randomized controlled trials dealing with the effectiveness of surgical sphincterotomy (SS) vs chemical sphincterotomy (CS) using botulinum toxin for the management of chronic anal fissure (CAF). METHOD: A systematic review of the literature was undertaken. Prospective randomized controlled trials on the effectiveness of SS vs CS using botulinum toxin were selected and analysed to generate the summative outcome. RESULTS: Four prospective randomized controlled trials dealing with SS vs CS using botulinum injection, which included 279 CAF patients, were analysed. Based on the random effects model, there was a higher complication rate [Risk ratio (RR) 14.54 (-9.84, -38.9) 95% CI, df = 2, P < 0.0163] and a higher risk of transient faecal incontinence [RR 6.39 (-2.37, -15.1) 95% CI, df = 3, P < 0.0001] in the SS group than in the CS group. However, there was significant heterogeneity among the trials (Q = 8 408 891, P < 0.0001), indicating a wide confidence interval range; thus, the inferiority of SS could not be shown. SS had a significantly higher healing rate [RR 1.63, (1.34-1.91) 95% CI, df = 3, P < 0.0110] and a significantly lower recurrence rate [RR 0.35 (0.33-0.38) 95% CI, df = 3, P < 0.0221] than CS. CONCLUSION: Both CS and SS are comparable in the management of CAF. There are no differences in the complication rates and incontinence rates between the two procedures. SS has a higher healing rate and a lower recurrence rate than CS. As long as the patient is willing to accept a negligible risk of transient faecal incontinence, SS should be the first-line treatment for CAF.

I like seeing that studies are being done to improve our condition, thanks all.
I worked out yesterday and now I've got an external hemmy that is kicking my ass, what is the best way to get rid of this awful thing?!

You might try over-the - counter creams for a while and Tucks , but if it becomes VERY painful and purple in color it might need doctor's attention. They make a small cut to drain it :(
Did you do "weight training" That is a no-no if you have colorectal problems

Oh - btw - maybe you can increase the No of times you apply your cream. I used Nitro and Nefid. at least 5 times a day !
I just read in one article that creams have effect for about 90 minutes and that might not be enough in your case to promote complete healing.

I'm with Fissulyna on both counts. The "apply ointment 2-3 times a day" advice never really made sense to me. When I was using the ointments, I got noticeably more relief when I used them much more frequently than that. The number of times I used them was limited only by some skin irritation (mostly itching) I'd get when I used it too often.
And yeah I'm impressed that you managed to work out with a fissure! Whether it was weight lifting or anything else, I'm not sure how you did it. My damn fissure severely limits any kind of exercise.
I used to have hemorrhoids and the fissure diet took care of them in the long term. In the short term I got a great deal of relief from the OTC creams. I personally particularly liked Preparation H "Cooling Gel" (witch hazel). My wife had hemorrhoids after being pregnant and liked the hydrocortisone creams a lot, but I've tried pretty much every kind out there (sadly) and am definitely partial to the witch hazel based ones.

I used Diltiazem twice daily (am and bedtime), and also b/4 BM's when my fissure was troubling.