So I have been reading the forum and if others are suffering from the pain I have I feel sorry for you all, no one should have this happen to them.
Background: Last July I went to my GP to finally get my hemorrhoid looked at and taken care of. He had given a RX for this 6 months previous and told me to change my diet and that they should clear up. They got a little better but never really went away so now I wanted a more permanent cure. He referred me to a Surgeon who I got into see rather quickly and by Sept last year I was scheduled to have a banding. All seemed to go ok but within a few days of the procedure I started to have a little pain. The Doc said that would be normal for the first week or so and I didn't pay much attention to it. After about 2 weeks I could still seem to feel something hanging out after a BM and it continued until I went back for the follow up 4 weeks later. After the Surgeon examined me he said I still appeared to have a rather large hemm back there and one of the bands must have come off which sometimes happens. He said he could do another banding in Dec. which I scheduled and did. Well about a week after this procedure something started to not feel right. The pain I was getting after a BM was nothing like after the first time I had the banding procedure so I quickly got back into see the Doc. He said I probably had a fissure and gave me a RX for Diltiazem. I used this for a few weeks but still seem to have the pain and it seem to be getting worse. The Doc gave me another exam and felt around with his finger but said he couldn't feel any fissure. He scheduled me for a CT scan but I am not having that till end of June. In the meantime, the pain has gotten so bad I cannot even go to work several days a week and luckily have been able to hide out...errr... work from home. The pain doesn't happen during a BM but about 10-15 min after I am buckled over. This last for about 6-8 hours and then subsides and goes away. During this time I can feel pressure almost like I have something in there that needs to come out. I try to see if I have to go some more but nothing comes out. That pressure feeling also goes away when the pain does after about 6-8 hours so it is obviously related. After going back to my GP for a second opinion he referred me to The Rudd Clinic in Toronto. (details of this nightmare are in another thread) Anyway they stuck a scope up me and said I had a fissure and anusitis. They RX me Diltiazem and told me I needed to try that for 4-6 weeks and if it didn't work they would recommend LIS surgery. I told them I had used it before but it did not help. When he asked if I put it right in my but I said no, the surgeon who prescribed it to me before said I only needed to put it on the outside of the rectum and it would be absorbed into the body. The Rudd Doc claimed that would not work. ........So here I am with 2 Docs telling me different things. One being a General Surgeon saying I don't have a fissure because he couldn't feel or see it combined with the fact that the crиme he gave me didn't help. The other Doc, supposedly more specialized in bum problems, telling me I have a fissure and that I need to try the medicine route. Meanwhile I suffer almost daily - luckily I only have a BM every other day. This has allowed me to go to work some days to show my face and keep anyone from finding out I am useless 2-3 days a week.
Sorry for the long winded story but I thought the history would help with opinions if you knew my story. That all being said. Does the pain I describe sound like a fissure? Secondly, since I tried the creme and it didn't really work do you think I should pressure one of these Docs to go for the Surgery instead of waiting since I am of the opinion that even if I didn't put the creme all the way in I am sure some of it was absorbed and yet it didn't help my situation. I hate to suffer with this another few months only to find out I need surgery and wasted all that time I could have been recovering.

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

Fissure pain is very ummm "enigmatic" so honestly I wouldn't go by feel alone. I have hemorrhoids and they've never caused me so much pain that I couldn't go to work. My fissure, on the other hand, was quite readily capable of causing such severe pain. So if I had to guess, I'd put my money on it being a fissure.
The main thing to consider IMO is whether anyone has visualized the fissure. It sounds like the Rudd Clinic actually visualized it when they scoped you. If that's the case, then it's almost guaranteed to be a fissure. The fact that another doctor couldn't see it doesn't mean much to me, because these things can be missed (they can hide in folds of skin or beneath stool), especially if it was with the naked eye rather than a scope. If you're not sure, I would seek one more opinion and ask them to do an anuscope. If the fissure can be seen, then that's the right diagnosis, period.
About the diltiazem and other ointments: there's no standard "best practice" as far as how to apply it. Many of us have been told different things by different docs and the actual medical literature doesn't always agree either (same goes for Botox injections for treating fissures). I always liked getting it inside the anus using a small oral baby syringe, but that was just personal preference. If you tried it on the outside before, then try it on the inside this time.
So to summarize, I'd say:
* Fissure pain can change. Mine started off only during BMs and was very sharp. Then it became a tight pressure feeling. Then later on it become both dull and sharp. Sometimes it could last for an entire day, and other times just 20 minutes or so. Pain is a poor guide to identifying fissures IMO.
* Make sure the fissure is visualized before you commit to surgery. But if it is indeed visualized, then LIS may be your best shot, since the fissure has been around for a while and is considered chronic by now, reducing the chances that diltiazem or any other ointment will cure it.
* Based on your description and my personal experience with hemorrhoids and fissures, I would guess it's a fissure. Hemorrhoids never put me into supreme agony and the pain from them never lasted 8 hours either. Only my fissure ever did that.
* Don't obsess too much over how to apply the ointment. Do what you think makes sense. Doctors are going to have their own opinions, and none of it should be considered law. Also, if you feel like you want to try something other than diltiazem (like nifedipine or nitroglycerin), be sure to ask. Some people respond to the various ointments differently.
* Finally, if you do indeed have a fissure, and would rather not have surgery, Botox is another option to consider. I did it and it was GREAT for a few months, but eventually my fissure returned. But for some people it works permanently, and IMO there isn't too much to lose by trying it aside from time.

NeuropathicGuy wrote:I always liked getting it inside the anus using a small oral baby syringe, but that was just personal preference.

And not to make light of the situation or anything, but man ... I hope no one ever reads just this one sentence from me and takes it out of context

That's excellent advice NG!
There are lots of sentences on this site that would raise some eyebrows if taken out of context ... like "I prefer to use a Q-tip to get it up by butt", for example :D
Redcharger, I know this is a very difficult decision, and it is particularly difficult because it's hard to think clearly when in so much pain. Whatever you decide to do, we are here for you!

NeuropathicGuy wrote:

NeuropathicGuy wrote:I always liked getting it inside the anus using a small oral baby syringe, but that was just personal preference.

And not to make light of the situation or anything, but man ... I hope no one ever reads just this one sentence from me and takes it out of context

I almost choked on my water i was drinking when I read this and started laughing!
Thanks for your input, both of you.
I wonder if anyone (CRS) in the Toronto area does Botox. I would think it being a accepted treatment that Rudd would offer it but they don't from what I've read. I may try to get an appointment with the other Doc who did my Hems and see if he would be willing to try the Botox. Although he hasn't helped me currently I like him a lot. He did my colonoscapy last year as well as removed my appendix and a piece of my colon when a polyp was found. His bed side manner is excellent. I just don't think he has come across a case like mine before. I mean he did get me scheduled for a CT next month, which here in Canada is quite a feat to happen so quick. He is trying to figure things out and I would prefer he keep treating me.

RedCharger wrote:He did my colonoscapy last year as well as removed my appendix and a piece of my colon when a polyp was found.

Wow. Dude! If you had an appendectomy and polyp removal (was it a colon resection?), then if you decide to go through with LIS, it's going to be absolutely NOTHING by comparison! The recovery timeline could be a bit longer since the anus gets so much daily use, but the procedure itself is very minor compared to those. We'll definitely be here to support you should you go through with it, but I think we (at least myself personally anyway) should be looking to you for support given what you've already got behind you (no pun intended).
Botox is one of those things that some doctors believe in and others don't. So I wouldn't be too surprised if a particular place doesn't do it. The success rates are considerably lower than LIS, so IMO I would only really consider it if you have reservations about LIS. In my case, I wanted to try every conservative measure reasonable before committing to surgery, so I'm happy I gave Botox a go even though it ultimately didn't help. Just gave me that peace of mind of knowing I tried it, ya know?
Let us know what you decide man. You'll get this taken care of one way or the other. It's just a matter of time.

I recall a discussion with my CRS where he said that many people are under the mis-impression that hemorrhoids are pain full. He says they are not, unless some other complication (AF, etc) also exists.

NG, it wasn't a full resection. He just took a corner off my colon where the appendix attaches. The polyp was right at the opening and he couldnt get it with the snare they use during colonoscopies. I had the procedure done on a Friday and was out by Monday morning. Doc said i would be laid up a couple weeks but I felt fine and had no real pain. Was a little tired and my stomach muscle were sore but other than that I was back to work on the Wednesday. I'm not concerned about having the LIS only that I could end up with the incontinence they warn could happen. Although from what i've read here that doesn't seem to be something many who have had the procedure are complaining about.

Well, incontinence is a risk, only u can decide if the risk is worth it. After a year of suffering the exact pain you describe, I knew that I'd rather wear a diaper til I die than go one more day with the burning that never stops. I'm sure I was on the road to healing a few times, unfortunately it only takes one bad day to put u back at square one, and let's face it, you're gonna have the odd bad day. You, and everyone else here deserve to get your lives back! I was so sure I'd be the one person for whom LIS makes no difference, or become instantly incontinent but, lucky for me, I'm like most ppl here and it worked! It's been three weeks today, red, and I feel better everyday, I could do all my normal things, aside from heavy lifting, after a week or so but it was clear to me, only 24 hrs out of surgery, that the burning was GONE. Everything else, I can deal with but that burning, throbbing pressure is GONE! I can laugh, cough, sneeze, enjoy my kids, weed flower beds, make plans, things don't revolve around my ass anymore! For me, it was definately worth the risk. Bottom line. IMO, if it's been like that for more than a few months, no ointments gonna heal it. I only tried nifedipine and Botox but the first didn't work except to numb the area for a short time, and for me, Botox made it worse. LIS was the best thing for me but you have to decide how much time you're willing to sacrifice. I hope your decision comes as easily as mine did and I hope at least you're having a good butt day today!