Oh and sweet bugaboo...just to add... I've never had any bleeding with any of my fissures, but am brought to tears daily with the pain... even the deepest ones that have torn down to the muscle itself have never bled. Go figure. Fissures are odd things in so many ways.

jr2 -
It's great that you're researching this info, and it really sounds like you have a good medical understanding of it all -- but does it say anything about posterior AFs?
My crs wants to keep trying the conservative treatment - fiber and keeping the area dry.
I don't know . . . I'm seeing a different crs (third crs for me) next Thursday.

Anterior anal fissures are associated with occult sphincter injury and abnormal sphincter function.
AuthorsJenkins JT, et al. Show all Journal
Colorectal Dis. 2008 Mar;10(3):280-5. Epub 2007 Jul 26.
Affiliation
Department of Surgical Gastroenterology, Gartnavel General Hospital, Glasgow, UK.
Abstract
OBJECTIVE: The pathogenesis of chronic anal fissure (CAF) remains incompletely understood but most are associated with a high resting anal pressure and reduced perfusion at the fissure site. To date, no major distinction has been made between anterior and posterior anal fissures and their aetiology and treatment. We compared anterior and posterior fissures in patients who have failed to respond to medical treatment with respect to their underlying aetiology, anal canal pressures and sphincter muscle integrity.
METHOD: Seventy consecutive patients (54 female:16 male) with a symptomatic CAF and 39 normal controls (19 female:20 male) without evidence of significant ano-rectal pathology were prospectively assessed by manometry and anal endosonography.
RESULTS: Anterior anal fissures were identified in a younger age group [33 years (IQR 26-37) vs 41 years (IQR 36-52)] and predominantly in women. Anterior fissure patients were significantly more likely to have underlying external anal sphincter defects compared with posterior fissures [OR 10.9 (95% CI 3.4-35.4)]. Maximum resting pressure was not significantly elevated for anterior fissures compared with controls (P = 0.316) but was significantly elevated in posterior fissures (P = 0.005). The maximum squeeze pressure was significantly lower in the anterior fissure group [167 cmH2O (IQR 126-196) vs 205 cmH2O (IQR 174-262), P = 0.004]. A history of obstetric trauma was significantly associated with anterior fissure location [OR 13.9 (95% CI 3.4-55.7)].
CONCLUSIONS: Anterior anal fissures are associated with occult external anal sphincter injury and impaired external anal sphincter function compared with posterior fissures. These findings have implications for treatment, especially if a definitive procedure, such as lateral internal sphincterotomy, is considered.
PMID 17655720 [PubMed - indexed for MEDLINE]

Jr,
You know after looking at the last two paragraphs again, it makes me wonder if my CRS isn't right.
But then the nifedipine is helping... I think...
How could lowered maximum squeeze pressure cause a fissure?
Is my butt just not getting out of the way of the poop?
Maybe I should start doing kegels again?
can you send me the link to where you got this so I can show my CRS at the end of Feb.?
-woi

Woi...
Fissures are confusing things... Actually, I feel like doctors and researchers know less about chronic fissures than they suggest in their usual boxed in thinking. There are a lot of people who have chronic fissures who have no evidence of internal sphincter spasm or elevated internal anal sphincter pressure. Further, there are plenty of people for whom surgery fails, and also plenty of people who do have surgery only to get fissures again at some point in their life.
the complex interplay taking place biochemically between the internal and external anal sphincters when producing a bowel movement makes it seem that somehow more than just the internal anal sphincter is involved for some people with chronic fissures. Years ago when I had my pelvic floor dysfunction evaluated bt a physical therapist she couldnt believe how weak my squeeze pressure was of the external sphincter. It barely registered on the biofeedback machine. But I do also clearly have too much tightness in the internal anal sphincter... Which makes me wonder here for a second... Is it possible that the internal anal sphincter compensates for a weak external anal sphincter by becoming tighter in order to maintain continence? Interesting question.
I found a book on Amazon written by a PT who provides really good exercises for the pelvic floor, which includes of course the anal area. Let me know if you'd like the title.
The link to the study I posted above is as follows:
http://www.ncbi.nlm.nih.gov/m/pubmed/17655720/

Thanks Jr,
Have you found these exercises to be helpful?
Are they different from Kegels?
If you don't mind my asking, how do they test the squeeze pressure of the external sphincter?
Please send me the book info.
I am just mystified as to why I have a fissure. I think I am too tight there but not crazy tight, but don't have spasms.
I always wonder about a possible connection to my episiotomy, but the docs just shake their heads. But then I wonder about changing hormones too. That is the only change in my life (other than the stress from the 'great recession') in the last couple years. Since I started to have issues with my butt.
Maybe it is stress. Stress and perimenopause!
anyways, the more info the better, I always say.
-woi

Woi...
I have found various different things helpful at different times. The book does cover kegels in various different types and forms, as well as massage, stretches, etc.
Here is the link if you want a peek ... http://www.amazon.com/Heal-Pelvic-Pain-Strengthening-Incontinence/dp/0071546561/ref=sr_1_2?ie=UTF8&qid=1328043476&sr=8-2
I think fissures are very complicated, and I don't think there is one answer as to why we get them and why they don't heal... There are plenty of people who have no sphincter hypertonia who still have chronic fissures, and plenty of people who have persistent fissure problems following surgery... Sometimes multiple surgeries.
I definitely think an episiotomy scar can have some role in fissure formation... Scar formation so close to the sphincter muscles will create greater rigidity and less flexibility in the area. And I do think hormones and hormonal changes play a part too...hormones, particularly estrogen, are involved in skin elasticity and suppleness, as well as playing a role in wound healing. And progesterone is a constipation culprit for many women..
And of course... Add on top of it stress/anxiety and you have a good mix for delays in healing...

Thanks JR,
I will look into it. Kinda hate to do any stretches right now as I have tons of water retension which isn't helping matters.
I did get the 'sqatty potty' stool a couple days ago and have used it twice. I will write about it when I decide what I think. So far so good though.
Hope you are having a better day!
-woi

jr,
I too think that having an episiotomy scar can have something to do with it, though why mine would come up years after having my one child, and bite me, is a mystery.
Also, I used to take estradial before I came to the States - some form of estrogen - and I wish that I had never stopped, because of all the darn worry about heart disease. The way I feel now I would rather have taken my chances than lose the elasticity that may have caused me to have a presumed-fissure (I say presumed as the CRS I saw last year could not find it...).
This is an awful situation we are in. Life is on hold. Not a way to live.
S

woi...
oh, I look forward to the squatty potty full review!
days of just horror over here... Still can't figure out where these hard dry stools are coming from... I do the same things with the same fiber . water . softener ratios every day and I'm not at a point in my menstrual cycle where I usually have a little more trouble... * sigh
S
For one of my fissures back in 2000 or so I started using estrogen cream on the fissure (just a tiny bit so as not to aggravate my endometriosis or cause any problems because of unopposed estrogen ) after reading about success with wound healing using topical estrogen. I wish I had kept a notebook of all these trials and how they turned out... I know something eventually worked because I was fissure free for about 4 years after... I just don't remember if the estrogen cream played a role or not.