After months of severe pain, I was recently diagnosed with an anal fissure and given treatment for that and for hemorrhoids. The first use of the hemorrhoid treatment completely suppressed the symptoms. I'm sure there is an anal fissure there, but I suspect that was never the cause of the severe pain. After 11 days, the once per night treatment is starting to get less effective and I'm wondering what the actual condition is and what a better long term treatment might be.
I got diltiazem ointment (four times daily) for the anal fissure and hydrocortizone suppository (one at bedtime) for the hemorrhoids. I started the suppositories a day before the ointment. All the symptoms were gone the morning after the first suppository before I ever used the ointment that is supposed to take weeks to work. I am still using both anyway.
I have had a lump in the left side of the opening my whole life. I have always had to slowly press that inward after a BM to avoid serious pain later. When I was young, the lump tended to be stretched outward during a hard BM causing pain during the BM. But that part of the problem stopped when I got older. I have no guess whether that lump is related to the more serious condition or just a distraction.
I have had chronic rectal bleeding my whole life, generally painless. When it occurs, it is at one of two very different quantity levels (never in between). Either just a little visible on the TP as I wipe, or a big flow difficult to stop after a BM. It is evidently coming from just inside the opening, but since it is painless, I don't know the exact spot. Probably, that is from the painless anal fissure that I think I have always had.
I have always had occasional episodes of extreme anal pain lasting 3 to 24 hours (about three times a year). Those seemed to correlate with eating certain foods that cause excess acid and failing to treat that promptly. Those didn't have any correlation with the bleeding. A specific spot in the left side that feels like it is an inch or two deeper in than the lump has always felt much worse that the rest of the area. This year those symptoms gradually became more frequent and less correlated with diet until it was happening at least 3 times a week with pain after every BM on those days that I wasn't in continuous pain. But other than frequency, it felt exactly the same as what had been occurring my whole life.
Unlike what I've read about anal fissure, it seems to be the chemical not physical characteristics of the stool that trigger the problem. The severe reactions are always caused by soft BMs, not hard. The doctor also said the anal fissure is in the "back" (which I think means what I would have called the "top") and is just barely deeper than what is visible when the cheeks are spread. But the very specific point of pain feels like it is at least an inch deeper in and on the left.
The instructions on the suppository said to avoid having a BM for at least an hour after inserting it (at bedtime). I expected that to be a problem. Even before these severe symptoms started, it has been very common for me to have sudden severe internal discomfort shortly after going to bed and needing a small BM (that recently has been quite likely to trigger the severe symptoms). I suddenly realized this morning that this has happened zero out of the last 11 nights (that I used the suppositories) and I don't think I've had 11 nights in a row without that problem any time in the last few years. I'm pretty sure it is some kind of inflammation (not the physical presence of a little stool) that always creates that need for a BM after I first try to go to sleep. The hydro-cortisone suppresses the inflammation.
The morning after the first suppository, the lump was completely reduced to a loose flap of skin. The lump came most of the way back by the time I inserted the second suppository and was reduced less each morning than the morning before. That point of pain in the left side didn't hurt at all for at least the first week. Then it returned to hurting a little on and off. It is still nothing on the scale of the pain I had before these suppositories, but it seems to be a little worse each day. So I'm pretty sure there is an underlying cause to the inflammation and the hydro-cortisone is only a short term method of suppressing it.
I had described the location of the most pain to the doctor before he inserted the scope. He is far from easy to communicate with, but I think I was clear enough that if there was something (like a second anal fissure) visible at the location of the pain, he would have found that.