Was doing okay last week, just a lot of itching at the fissure spot after movements but had a re-tear last Thursday and things have gotten worse. This morning's BM was very painful despite being soft overall, blood in bowl and on wipes and now I am in spasm and very clenched.
I put a call into my CRS to ask for another treatment or if I should come in before my appointment next Tuesday because this is so painful physically and emotionally I feel defeated. Right now my only treatment aside from added fiber, water, smarter diet and stool softeners is hydro cortisone suppositories at night which I haven't even been able to use last two nights because it's too painful.
I assume next step is Diltiazem or something similar but I have a few questions to those in the know. How is it applied (on fissure spots or simply around the anus in general) and what does it do? Does it help with the pain and spasming?
Something has to give here. Whether it's surgery or Diltiazem or something because I am just defeated and at about 50% effective in life and work because of this issue.

There are other threads on this board where Diltiazem has been discussed. You might try doing a search.
When I used Diltiazem, I applied it internally at least twice a day. It helps increase blood flow to the area and subsequent healing. Also helped with pain for me. An AF can really get a person down. No doubt about that!!

Some apply Diltiazem internally, others put it externally around the anus. It should help either way. You don't have to put it directly on the fissure. It increases blood flow to the area which can ease the spasms and promote healing.
I would definitely try diltiazem, nifedipine, or nitroglycerin before surgery. Frankly IMO it's what you should have been trying in the first place instead of messing around with hydrocortisone. I liked nitroglycerin the best myself but it also has the most side effects (which taper off with time) for most people.
I recall from an earlier post that your CRS had already told you that you could try diltiazem if the hydrocortisone didn't work. If it already came up in your previous discussions, then he or she should be able to prescribe it to you over the phone or at least have you drop by the office for a quick visit. It's baffling that a doc would tell you about diltiazem, then have you use just hydrocortisone for a few weeks

True, but when I asked about diltiazem she said that would be a course of action we can take but since the hyrdo cortisone had worked for me previously (last year under different doc) she said let's try that first and to call if things have gotten worse. Well things aren't worse than three weeks ago but they certainly aren't better.
When she calls I am simply going to tell her what I'm doing/using now isn't working, I am in constant spasm following Bms and I need whatever she suggests whether it's diltiazem, nifedipine, or nitroglycerin.
She said surgery is always the last resort so I assume this will be the next step. Heck, I don't even care if I have small fissure symptoms forever, but these big ones and the constant discomfort and pain and blood in the bowl has gotta go.
And yes, she should be able to prescribe it over the phone or I'm willing to swing to the office this week for another exam but not sure why that would be needed. I am scheduled for next week anyhow.
This is craziness. Thanks very much for your response though!

My first fissure healed in 1-2 weeks with just hydrocortisone suppositories too. In fact it probably would have healed without me doing anything (except stool softeners) at all. Most acute fissures heal with nothing except higher fiber intake and softer stool.
But once they go chronic it's a different story. At that point, using just hydrocortisone is likely just prolonging your agony and making the fissure harder to heal. The reason I say this is because I learned it the hard way myself. Here's my personal fissure story:
1. Got an acute fissure in May 2009. Was in SEVERE crippling pain. Doctor prescribed hydrocortisone and stool softeners. Symptoms disappeared in 1-2 weeks and I thought I was out of the woods.
2. Fissure returned with severe pain a month later in June 2009. Doctor prescribed hydrocortisone again. Used it for two months and it didn't do squat.
3. Finally had enough of the hydrocortisone nonsense and saw three different CRS in August 2009. At this point my fissure was at its peak intensity with terrible intractable pain and lots of bleeding. Tried nitroglycerin and nifedipine. Nitroglycerin worked better for me and got my fissure pain under control within 2 weeks. The fissure was still there, but I could go about my life with just mild-moderate discomfort and pain now.
4. Tried Botox injections in October 2009. Got several months of awesome relief from them. It was like having no fissure at all for the rest of the year.
5. Fissure symptoms, although mild, returned in February 2010. Tried diltiazem at this point. Didn't really do much for me so I returned to nitroglycerin. The fissure was still there but perfectly manageable.
6. Went for LIS in May 2010. Got an abscess at the incision site 2 weeks later and had to have a 2nd surgery to have it drained. Still having discomfort and discharge from the incision site right now. Discomfort is manageable but is more than I had before surgery. And I had no discharge prior to surgery.
I know it's a long story but my key takeaways would be as follows: when a fissure is acute, it has a very good chance of healing on its own, and anything from hydrocortisone to simply adding fiber to waiting it out may resolve the situation. But once a fissure is chronic, then nitroglycerin, nifedipine, diltiazem, Botox, and surgery are the only things that are clinically proven to help. The longer you hold off on proper treatment, the harder it becomes to cure.
The other key thing is that although none of the creams actually cured my fissure, they absolutely did get rid of the insane debilitating pain and allowed me to go about my life. I could drive, I could work normal days, I wasn't terrified of every bowel movement, I wasn't paralyzed with pain after every bowel movement, and I wasn't filling toilet bowls with blood.
I would agree with exhausting all conservative options before surgery. It's highly successful for the majority of people. But that doesn't mean it's a magic bullet. My personal fissure-related regrets are that number one, I didn't handle it more carefully when it was in the acute phase and could still be easily treated, number two that I delayed proper treatment for several months and instead listened to my idiot doctor who told me to just use hydrocortisone, and number three that even though my chronic fissure pain was very mild, I went for surgery instead of trying Botox again.