I first want to start this post with an apology. I have posted on this board off and on for many months, beginning a couple of years ago. I was first diagnosed with a superfiscial anal fissure back in 2006. I was subsequently diagnosed with another such fissure in 2008 and again in 2009. On all three occasions, the fissures healed with conservative treatment in a matter of weeks. My preference has always been to avoid surgery for fear that it could actually result in complications to an underlying pelvic floor dysfunction issue that I have had for the past 12 years that causes discomfor and pain in the rectum. I realize that because I have been on this board for so long and have posted so many times that I come across as being someone who cannot make up his mind about what he wants to do. This is very true. Because I have been dealing with underlying issues that are not related to fissures, I have been very discouraged and desperate for answers. The anal fissures have further complicated my condition taking me to a state of being able to cope to a state of absolutely not being able to cope. I would like very much to get back to the coping stage, if that were possible, but I have a major fear about pursuing LIS because I'm afraid it may not work in my case or that it could further complicate the condition that I have and would fail to cure my issue with recurrent fissures.
Having said all of that, I am sorry if I have come across as a whiner or someone who can't make up their mind. I have had some response to my previous posts, but not the response that I would have hoped. I am very grateful for those who have responded as the responses have been very helpful to me. I am very close to making a decision as to whether or not to pursue LIS. However, I live in an area where this procedure is not being offered to me and my only option right now is to find a surgeon out of state to do the procedure. This obviously brings up many issues and this is part of the reason for my indecisiveness.
Because of my unique situation, I would like to receive feedback from the many of you who have or are in the process of going through LIS. The questions that I have are as follows:
1. How long were you completely out of work and at what point were you able to return to work full-time as before the surgery?
2. How often did you follow up with your surgeon after the surgery?
3. How qualified was your surgeon in terms of the amount of LIS procedures he or she performed per month/year?
4. Did any of you have difficulty with bowel movements prior to the surgery due to rectal tightness that was alleviated by the LIS surgery to the point where bowel movements came with much less effort and ease as opposed to pre-surgery?
The reasoning behind my questions are because I would be traveling out of state and I want to get a general idea of how long I can expect to be away, etc. The one surgeon that I have spoken with out of state has told me he does about 30 procedures per year. This seems low, but as some posters have noted to me, this doesn't mean that he isn't experienced and wouldn't do a good job. But, I would like to know from those that have had LIS if their surgeons had more or less experience than this. And, one of my underlying issues is called anismus or pelvic floor dyssynergia, which is a condition that causes the sphincter to remain tight instead of relaxing during bowel movements and that causes difficult passing stool with ease and is the biggest reason for my fissure development. If I had LIS, I would be hopeful that this problem would be somewhat alleviated, but am not certain if that would be the case.
Thank you all for your help. I am really at a crossroads on what to do and am very frustrated and depressed over this and just not sure what to do.
Mike

Hi Mike,
I haven't had LIS but wanted to jump in and respond to you anyway. I too have pelvic floor problems, in addition to many other health problems that make LIS a lot riskier for me than for some others. I too have had fissures over the course of a lot of years. Currently I have multiple fissures and I can relate to the frustration. The problem with LIS when you have an underlying problem with the pelvic floor is that you are only addressing part of the problem, and not the problem as a whole. That isn't to say it isn't possible for LIS to help you with your current fissure problem but the odds of success may be a bit lower and the risk of fissure recurrence a bt higher. There is, as you suggest, also the possibility of worsening of your pelvic floor problems.
Have you ever had any treatment for your pelvic floor issues, such as biofeedback or physical therapy? It might be worth at least a consult with a physical therapist who specializes in pelvic floor problems and ask their advice about the LIS surgery and how it may impact you.
I wish I could be of more help to you. I'm sure some of the surgery veterans on this board can answer your questions about the surgical experience and the time it takes to recover, though even that is highly individual, with some feeling better very soon after surgery and others taking longer. In the presence of your coexisting pelvic floor problems, it might or might not take longer for your recovery.
I wish you all the best, and hope you are able to feel some peace soon about this difficult decision.

I completely agree with jr2. Have you ever looked into biofeedback for your pelvic floor dysfunction? I was also diagnosed with pelvic floor dysfunction, but was able to achieve remarkable success through a series of biofeedback sessions (recommended by my CRS). I no longer have to strain AT ALL to have a bowel movement.

I have pursued and received treatment for the pelvic floor dysfunction, which by the way, has been labeled everything from dyssynergia to chronic levator spasm to pudendal neuralgia. I spent three weeks at a pelvic floor dysfunction clinic in San Francisco where I received internal massage therapy as well as various injections. The therapy could have been beneficial, but because of the expense involved and because I love several hundred miles away, I could not continue ongoing treatment. I have seen various physical therapists in my city, however, none of the therapists that I have visited are familiar with or comfortable treatment men with this issue. I have not received any biofeedback, but I do have a PT that is able and willing to "try" the biofeedback with me, but she is not experienced with this therapy on men. I have not pursued the biofeedback because just prior to scheduling my first session, I developed the intense pain of an anal fissure and figured that the treatment would not be effective or tolerable with an anal fissure. That was back in December and I have not felt as though my fissure has healed and so I have not pursued the biofeedback.
Did you receive biofeedback while you had an active fissure? How did you finally relieve the issues with fissures or have you? I know that the Mayo Clinic has a program for biofeedback, but it is very expensive. Thanks.

A couple of things:
1. There was a recent study that showed biofeedback was superior to electrogalvanic stimulation and massage (physical therapy) for the treatment of Levator Ani Syndrome (LAS). In fact, 87% of participants reported "adequate relief" with biofeedback (as compared to 45% for EGS, and 22% for massage).
Here is the link to the study:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2847007/
Personally, I would HIGHLY recommend biofeedback. Obviously, if you continue to strain or push to have a bowel movement, it will be very difficult or impossible for your fissure to fully heal.
2. I would ONLY go to a nurse or specialist who is highly trained in administering biofeedback. In fact, the nurse I went to (in South Carolina) says that people fly in from all over the country to see her because it is so difficult to find someone who is properly trained in biofeedback. Each session costs about $450 (without insurance) and lasts about an hour to an hour and a half. Some people only need a couple of sessions. In the study cited above, each participant went for 9 sessions. I was able to achieve lasting results in 4 sessions. To be perfectly honest, I was very skeptical about biofeedack when my CRS first mentioned it to me, but I have been amazed at the results (I no longer strain AT ALL to have a bowel movement).
3. No, I did not have a fissure when I first went for biofeedback; however, if you do have a fissure, the nurse can place the strobes on the outside of the anus (as opposed to inside the anus) and achieve the same results. You definitely would NOT want to insert the strobe if you have a fissure. The end of the strobe is at least 1/2" wide.
4. After using Miralax daily (a lifesaver for me!) and Nifedipine for 6 weeks, my CRS says he thinks my fissure is finally gone. I am still experiencing some pain and discomfort following a bowel movement, but my CRS thinks it's because I am still dealing with LAS.
5. While somewhat controversial in mainstream medicine, many people with LAS have reported success using the principle's in Dr. John Sarno's books to "cure" them of LAS. Sarno's theory is, in part, that the pain is an unconscious "distraction" to aid in the repression of deep unconscious emotional issues. Sarno believes that when patients think about what may be upsetting them in their unconscious, they can defeat their minds' strategy to repress these powerful emotions; when the symptoms are seen for what they are, the symptoms then serve no purpose, and they go away. Dr. Howard Schubiner has also done some seminal work on the subject, and has said that he believes LAS is a common manifestation of Mind Body syndrome. Here are some links for both of them (you can also find their books, along with lots of helpful reviews, on Amazon):
http://www.healingbackpain.com/
http://www.unlearnyourpain.com/
Both my CRS and my biofeedback nurse believe there is a connection between the emotions and LAS.
Of course, you should ALWAYS check with your doctor before beginning any treatment.
I hope this helps!

By the way, what kind of injections did you get? Did they help at all?

Great info, thisfissure! It's good that you post it, because there is more than one way to approach an AF. Many people have success with LIS surgery - but for some people, it's not an option - or maybe it's a riskier option. --- So, that's what this forum is all about - getting information and offering support.

Thank you for the responses. I really appreciate it. I have a few biofeedback specialists that I have corresponded with around the country, so if I pursued that, I would definitely choose a specialist. The injections that I received were steroid injections and they were "nerve blocks", unfortunately, they did not help. I had the most benefit from the internal physical therapy. I would prefer to pursue something less invasive like biofeedback before going for LIS, but I just don't see how the biofeedback could be effective with the amount of pain that I am in with the fissure. I'm leaning toward pursuing the LIS and then, hopefully, if everything goes well and the fissure heals, I will pursue biofeedback. I just wish that I had a CRS locally that would do LIS, because I really don't like the idea of surgery out of state with so much uncertainty.
What are your thoughts on pursuing LIS first and then biofeedback? Have you heard otherwise from PT's?
I am also familiar with Dr. Sarno as well. I actually believe alot of what he has to say. Unfortunately, having the anal fissures makes it more difficult to apply his methods, because as I recall, his methods are more geared toward "unexplained" pain, but I could be wrong.

Hi Mike:
Yes, you are absolutely correct - the biofeeback or TMS treatment (i.e., Dr. Sarno and Dr. Schubiner) would only help with the underlying pelvic floor disfunction, not your current fissure. However, the continued pelvic floor disfunction may keep your fissure from healing, so if you can get the pelvic floor issues under control it may help you heal the fissure without LIS.
In addition, even if you are able to heal the fissure without LIS but the pelvic floor issues continue, you are likely to just get recurring fissures.
Of course, if you opt for LIS, fissures would no longer be an issue.
I think you may be pleasantly surprised at how much pain relief you can achieve with biofeedback if it is successful for you. A good biofeedback specialist should be able to tell you at your first visit whether or not they think they can help. When I was first diagnosed with LAS, I know I was absolutely shocked (SHOCKED!) that a muscle spasm could cause such debilitating pain. I am very glad that I went to biofeedback. I learned a lot about how the pelvic floor muscles work, and what I need to do to control them.
A couple of questions, if you don't mind:
1. Were the steroids injected directly into your levator ani muscle? What was the experience like? Were you under anesthesia? Did you have much post-injection pain? Did you have any other post-injection side effects? Did the injections even work for a short period of time, or did you know right away that they were ineffective?
2. What was the physical therapy like? Was it uncomfortable? How effective was it? Didn't they teach you how to continue treatment on your own at home?
Thanks in advance for any feedback you can give.
I'd also be happy to answer any other questions you have about biofeedback.

thisfissurecankissmybutt
Were you given helpful exercises to do at home that you can share, or do you know of a good book on the subject? I had a round of PT some years ago, and a few sessions of biofeedback, but I didn't find my therapist particularly knowledgeable about pelvic floor issues. While I would love to go back for more therapy I can't swing that right now with all of the other health issues I'm dealing with. I have Amy Stein's book and some of those stretches are helpful, but I wonder if you have any other recommendations?
You are really correct about how the pelvic floor issues do contribute to recurring fissures. I know it's true in my case. When you look at the anatomy and see how the levator ani muscles encircle the sphincter muscles it really is no wonder it contributes to fissure issues.