Besides high blood pressure, I'm an otherwise healthy 46 year old male and I have had severe, chronic fissures (with sentinel pile) for 12 weeks. I first noticed something wrong months before that. I don't like going to the Dr but I wish I would have seen one much sooner. It got worse and worse until it was almost unbearable. It started because of repeated constipation and pushing too hard to go. Getting better will take a big commitment, but if you feel the pain that I did, then you are properly motivated. I feel a duty to share the following list. These are the things that have worked for me so far. I'm doing better, but I’m still in recovery.

1. Make an office appointment with a colon and rectal specialist/surgeon (CRS). My regular doctor (GP) didn't know anything about AF. I wasted weeks with him. He put me on hydrocortosone suppositories which actually can make it worse. I recommend bypassing the GP and going directly to a CRS. Usually the Dr doesn't need to stick anything up your anus to diagnose AF so don't be too worried about the appointment. I was terrified for no reason. You will most likely get a prescription for nifedipine or some other cream that is meant to relax the internal anal sphincter which is causing most of the pain and is preventing healing of the fissure. Start using it as soon as possible. It is not a miracle cure and doesn't work at all for some people. It hasn't done much for me. If the cream doesn't work, the next step is Botox injections into the sphincter to temporarily paralyze it. If that doesn't work, the next step is LIS surgery. Getting to the thing that fixes the problem can be a long process so start asap.
2. Soften your stool: If your AF is due to constipation, this is the biggest factor in healing and avoiding some of the during and after-bm pain. Take miralax and magnesium daily. I take miralax in the morning and magnesium citrate at night. Drink lots of water. Eat foods with lots of fiber like fruits, vegetables, raisin bran with almond milk, fiber one bars, etc. I occasionally (not daily) drank psyllium fiber supplement. I didn't want more stool, but I think it did help keep it soft. Don't overdo fiber. Do not eat meat, dairy or anything that might cause constipation. I’ve lost over 30 pounds during this nightmare, and I'm not overweight to begin with. I was afraid to eat.
3. Relax the internal anal sphincter: Take sitz baths in extra virgin coconut oil. I take at least one ½ hour bath per day, always after BM. These hot baths relax the sphincter. Coconut oil helps heal the skin. Use the hottest water you can stand. Use a heating pad or hot water bottle if you can't take sitz baths during the day. Heat was really the only thing that has helped lower the after-bm pain for me.

Healing is a slow process so you have to be patient and bear the pain. There are almost always setbacks too. I've had several. Just when I think I'm getting better, I relapse. It's very frustrating. I tried many other otc remedies that did not work. I also didn't know what my problem was until it got out of control. I had never heard of AF - wish I never had. I could have avoided this all by starting on miralax before I got the first fissure. The sooner you figure out what it is and become an expert in it, the sooner you can get on with your life. I’ve learned a lot here.

Other tips/details:
1. After you find what works for you, stick to that routine every day, especially the BM routine.
2. Prop your feet up on something while you're going.
3. Don't wipe much with TP after BM. Use hemorrhoid pads with aloe or some other moist towelette, and try not to wipe with it. I cleaned up in the shower. I think that's best.
4. Take a 30 minute sitz bath following BM. Then dry off, wait 15 minutes and apply nifedipine or whatever the CRS prescribes. You have to get a little cream in the hole with the head of a Q-Tip. It hurt less than I thought it would.
5. Use a blow dryer on warm/cool to dry your butt. I've heard it's best to try to keep it dry. Not sure how much that helped but it didn't hurt.
6. Sitting was the worst position for me. Laying on my back was best. I can't drive for hours after BM. I reclined as far as I could in the bath.
7. Ibuprofen was the only pain killer I took. Acetomenophen/tylonol makes constipation worse. I don't think any otc pain med does much for this pain.

Of course it is best to avoid AF altogether. If you are so constipated that you have to push very hard to get anything to come out, STOP. I pushed hard repeatedly causing the fissures. Give yourself an enema. I'm no fan of sticking things up there, but I would take a thousand enemas over a single AF. Once I had an AF I couldn't take a saline (fleet) enema because it stung so badly. I think an enema should be used temporarily to break down hard, dry stool so you don't have to push so hard to pass it. Change your diet or prescription drugs to fix the constipation problem long term. I think miralax is great for that. I plan to use it long term and add more fiber supplement once the AF has healed.

During this horrifying ordeal I cried like a baby more than I care to admit, and I don't cry. The pain, fear and anxiety are overwhelming. I lost all hope several times and didn't want to live. I've said in the past during a bad illness like the flu that I just wished I would die, but I didn't really mean it. I really meant it with AF. If it wasn't for my wife, I might not be here. That sounds dramatic, but it's true. If you have it like I do, you know what I’m talking about. My worst pain starts 1 to 2 hours after BM. The worst pain lasted about an hour, sometimes longer, sometimes shorter. I have had bad pain last for 6 hours after BM. I think I have a very strong sphincter. I’m doing much better recently but live in constant fear. Good luck to all the sufferers.

These are solid tips and reminders Dnank. Thank you for sharing your feelings and struggle. Even though I have dealt with for a long time and my fiancé is supportive, I often feel shattered emotionally and alone. It is so helpful to read that others feel the same way. I hate that others feel this way, but it certainly makes me feel less alone about it all knowing others share in the physical and emotional stressors of this condition.

I'm slowly making positive progress. I'm having a little less during, and more importantly, after-bm pain each time. My sentinel pile is less than half the size it was 2 weeks ago. I'm sticking to my routine, including all the things I listed above.

Thanks for your comment, Manitourose. Reading everyone's posts in this forum has helped me when I really needed it.

The nightmare continues. Had a bad one last night. The after-bm pain was terrible and lasted for hours. Oddly, the during-bm pain wasn't bad. I took a little milk of magnesia for the first time ever before going yesterday because I hadn't gone for nearly 48 hours. Could that make the pain worse? I'm not having to push too hard to go now so I don't think I'll take it any more.

Thank you for sharing. Its good following on somebodys progress. Hope youre better now.

Still struggling. I started a diary to keep track of things: af-diary-t10163.html