Hi Redcharger - you have really had a rough go of things for quite a while! I'm so sorry you are suffering with all this.
You didn't really describe the kind of pain you are experiencing. Is it a burning/throbbing/tight kind of pain? If so, then it could be the sphincter spasming because of a fissure.
Also, I thought that internal hemmies didn't hurt very much, unless they are grade 3 or 4 and/or are thrombosed. (I know that external ones sure hurt!) But, I'm thinking that if you don't have a grade 3/4 thrombosed internal hemmie, then a fissure probably explains your pain. Also, fissures can sometimes be difficult to detect, so I would be inclined to believe the butt expert (even if he is a sadistic SOB!). Inflammation of anusitis could cause the feeling like you need to go - although that feeling is pretty common with hemmies as well. But, as I said, I think that if hemmies were causing the extreme pain, then no doctor would miss them. Maybe others can chime in about this.
As for applying ointments: I'm pretty sure that you are supposed to put about a pea sized amount of the ointment right up there. At least that's what I've read in my own research, so I think you got the better advice from the Rudd doc.
The decision about surgery is a very personal one. I don't want to suggest one way or the other, but I definitely understand where you are coming from! I tried the dilt for 4.5 weeks, but after suffering for a few months already, and with the pain getting so bad, I felt I had no choice but to get the surgery. When I went to the Rudd for a follow up after trying the dilt, I got the surgery right there and then - no pressure needed (as you may recall from my story!). So, I'm guessing that you might be looking at 4-6 weeks to try the dilt and then surgery pretty much right away, if you stay with Rudd.
I think you'll know when you can continue with the dilt and when you need to stop that treatment and get surgery. For me it came down to not feeling I had a choice anymore. I really understand your pain and your concerns! I'm sorry I can't be more helpful ... but you definitely have my sympathy