Has anyone mentioned Levator Ani Syndrome (LAS) to you? I was diagnosed with LAS over a year ago and your symptoms are very similar to my initial symptoms. You can read about the basics of LAS on the Wikipedia page for Levator Ani.
Here is the link:
http://www.google.com/search?q=levator+ani+syndrome&ie=UTF-8&oe=UTF-8&hl=en&client=safari#itp=open0
It is easy to diagnose LAS, but many doctors and even many CRS's don't consider LAS because it is not very common (my CRS only sees about 6 to 12 cases a year). Diagnosis is made by a simple digital exam (i.e., a doctor or physical therapist specializing in pelvic floor dysfunctions inserts their finger in your anus). If you experience tenderness when the doctor or physical therapist presses on your Levator Ani muscle, you might have LAS. If so, this may explain the source of your pain. It's worth looking into.
Good luck!

Thisfissurecankissmybutt,
Thanks for your suggestion. My most recent CRS did mention this and considered it as a possible etiology. He also noted a fissure. He felt we should treat the fissure first and then consider treatment of L ani syndrome if the pain has not resolved.
What are your symptoms associated with L. ani syndrome?

Well, here is a very brief overview: for me (and my experience might not be typical), it all started with a hard bowel movement that required me to push really hard. About 4 hours later, my butt started to hurt, but I noticed the pain was a little higher up and to the left. The pain lasted for about 8 hours. For the next several weeks, the pain continued but only after I had a BM (no BM = no pain). However, I never had any pain or bleeding during a BM.
After a couple of weeks, I went to my family doctor who did a THOROUGH rectal (digital) exam. The exam was pretty much painless. She looked for a fissure and fistula, but didn't find anything. However, she did say my sphincter was REALLY tight. She referred me to a CRS. However, as I left her office, I noticed that I actually felt better (which was an important clue that I didn't realize the significance of at the time - after most rectal exams, especially for those with fissures, the exam can be excruciatingly painful; however, I felt better because my doctor had essentially stretched my sphincter muscles which temporarily relieved my pain).
Of course, the next day, the pain came back after my daily BM.
Eventually, the pain I was experiencing would start immediately after a BM and sometimes last 8 to 12 hours (or more). In addition, due to my tight sphincter, I developed a fissure which turned into a fistula, which required me to have surgery for the fistula repair and LIS.
In any case, before the fissure and fistula, I found a wonderful CRS that correctly diagnosed me with LAS after other CRS's were stumped and just sent me home with more medication that did nothing for my pain.
I won't go into all of the details here, but my CRS tried everything to help relieve my pain (muscle relaxers, biofeedback, steroid injections, etc.) but nothing worked until I found a life-saving physical therapist that specializes in pelvic floor dysfunction. She was able to help me manage the pain through intensive internal stretching and other techniques.
Basically, although my symptoms seemed similar to those of a fissure, they differed in the following important ways to most (but not all) people suffering with a fissure:
1. No pain during a BM.
2. No bleeding during a BM.
3. The pain felt higher up in the anus, and to the left.
4. Rectal (digital) exams were not painful.
5. Rectal (scope) exams were not painful.
6. According to my CRS and PT, most people describe the feeling of LAS as though they are "sitting on a golf ball."
Of course, as you alluded to, it is possible to have both LAS and a fissure (or multiple fissures).
I hope this helps.

thisfissurecankissmybutt,
Thanks for the thorough description. In comparison to your symptoms, I have the following similarities and differences.
I have no pain or bleeding with BM's
The pain does feel somewhat higher up.
Rectal exams are however very painful as well as scope exams and the CRS has to use a pediatric scope given the pain and spasms they note during their exams.
Oddly enough, after the exams I do note substantial improvement in my symptoms. I always thought it was kind of weird.
Maybe there is a component of this syndrome.
What do you think?

I am not a doctor, but I think it's entirely possible that you have both LAS and a fissure (or multiple fissures). The LAS might have caused the fissure(s). If that's the case, you may need to address the LAS in order to allow the fissure(s) to heal. However, the only way to know for sure whether you have LAS or not is with a digital exam, which may be too painful for you to endure. Basically, your doctor or PT will need to stick their finger all the way into your anus and press on your levator ani muscle. If pressing on the levator ani muscle replicates the pain you feel, you would most likely be diagnosed with LAS.
If you don't think you can stand the pain of a digital exam, here is my suggestion: assume you have LAS and ask your CRS if you can treat both the LAS and the fissure(s) at the same time.
The first treatment my CRS tried for my LAS was muscle relaxers (i.e., Flexeril, Baclofen, etc.). The idea is to relax the levator ani muscle, which will reduce the spasms, which will reduce or eliminate the pain. My CRS told me that muscle relaxers work for his patients with LAS about 85% of the time. At the same time, you can treat the fissure(s) with Nifedipine or Diltiazem (or whatever your CRS prescribes).
Let me know if you have any other questions.

Hi thisfissurecankissmybutt,
I wanted to let you know that I had botox for a fissure. After the botox therapy the pressure actually became worse. I had a follow up with the CRS and he palpated my levator ani muscles and I pretty much flew off the table. I will be starting physical therapy for LAS in mid-september. (your suggestion was at correct that I may have LAS!) At this point I can barely stand and I mostly lay down or sit down if I have the chance. I am truly hoping that this therapy helps cure my pain as I have had it for two years now. I cant play with my 7 month old like I would want to.
If you have the time to answer...What was physical therapy like?
Thanks again for your suggestion!