After months of severe pain, I was recently diagnosed with an anal fissure and given treatment for that and for hemorrhoids. The first use of the hemorrhoid treatment completely suppressed the symptoms. I'm sure there is an anal fissure there, but I suspect that was never the cause of the severe pain. After 11 days, the once per night treatment is starting to get less effective and I'm wondering what the actual condition is and what a better long term treatment might be.
I got diltiazem ointment (four times daily) for the anal fissure and hydrocortizone suppository (one at bedtime) for the hemorrhoids. I started the suppositories a day before the ointment. All the symptoms were gone the morning after the first suppository before I ever used the ointment that is supposed to take weeks to work. I am still using both anyway.
I have had a lump in the left side of the opening my whole life. I have always had to slowly press that inward after a BM to avoid serious pain later. When I was young, the lump tended to be stretched outward during a hard BM causing pain during the BM. But that part of the problem stopped when I got older. I have no guess whether that lump is related to the more serious condition or just a distraction.
I have had chronic rectal bleeding my whole life, generally painless. When it occurs, it is at one of two very different quantity levels (never in between). Either just a little visible on the TP as I wipe, or a big flow difficult to stop after a BM. It is evidently coming from just inside the opening, but since it is painless, I don't know the exact spot. Probably, that is from the painless anal fissure that I think I have always had.
I have always had occasional episodes of extreme anal pain lasting 3 to 24 hours (about three times a year). Those seemed to correlate with eating certain foods that cause excess acid and failing to treat that promptly. Those didn't have any correlation with the bleeding. A specific spot in the left side that feels like it is an inch or two deeper in than the lump has always felt much worse that the rest of the area. This year those symptoms gradually became more frequent and less correlated with diet until it was happening at least 3 times a week with pain after every BM on those days that I wasn't in continuous pain. But other than frequency, it felt exactly the same as what had been occurring my whole life.
Unlike what I've read about anal fissure, it seems to be the chemical not physical characteristics of the stool that trigger the problem. The severe reactions are always caused by soft BMs, not hard. The doctor also said the anal fissure is in the "back" (which I think means what I would have called the "top") and is just barely deeper than what is visible when the cheeks are spread. But the very specific point of pain feels like it is at least an inch deeper in and on the left.
The instructions on the suppository said to avoid having a BM for at least an hour after inserting it (at bedtime). I expected that to be a problem. Even before these severe symptoms started, it has been very common for me to have sudden severe internal discomfort shortly after going to bed and needing a small BM (that recently has been quite likely to trigger the severe symptoms). I suddenly realized this morning that this has happened zero out of the last 11 nights (that I used the suppositories) and I don't think I've had 11 nights in a row without that problem any time in the last few years. I'm pretty sure it is some kind of inflammation (not the physical presence of a little stool) that always creates that need for a BM after I first try to go to sleep. The hydro-cortisone suppresses the inflammation.
The morning after the first suppository, the lump was completely reduced to a loose flap of skin. The lump came most of the way back by the time I inserted the second suppository and was reduced less each morning than the morning before. That point of pain in the left side didn't hurt at all for at least the first week. Then it returned to hurting a little on and off. It is still nothing on the scale of the pain I had before these suppositories, but it seems to be a little worse each day. So I'm pretty sure there is an underlying cause to the inflammation and the hydro-cortisone is only a short term method of suppressing it.
I had described the location of the most pain to the doctor before he inserted the scope. He is far from easy to communicate with, but I think I was clear enough that if there was something (like a second anal fissure) visible at the location of the pain, he would have found that.

Hi there and welcome! You have arrived in a place with a lot of friendly souls, happy to help, as we too have/are in the same place.
Is the doctor that you saw a colon and rectal surgeon(CRS)? I think they know a lot more about what is going on 'down there' than does a GP.
Also, I too saw a doctor who I was not impressed with, and looked further for one who would explain things to me and properly examine me under a procedure where I would be relaxed enough to not threaten to leap off the table or scream.
From what I know, the actual cause of the pain(that is if you have spasms after a BM) is the tightening of the involuntary internal sphincter. This becomes a viscous circle of pain as the muscle going into spasm, and because of this tightening, no blood can get to the area, hence the Diltiazem to relax the area and supposedly then also blood to reach there and healing follow. Trouble is, doesn't always work. I have tried Diltiazem and Nifedipine and neither worked in the long term.
I also have hemorrhoids, but having had three previous surgeries for this there is no way that I will ever go through that again.
Hydrocortisone is for very short-term use for hemorrhoids and does nothing for fissures, as far as I am aware. Also, H.C. thins the skin in the area.
There is a lot of information on the forum. Do take the time to have a look through this as you can get a good idea of what has helped and what has not helped people. Also the search facility top right is very good.
Really glad that you have found some relief in the evenings, and long may it continue. That is the only time I am free of pain and that heavy feeling, when I sleep after taking 0.50mg of Lorazapam.
Sitz baths are good too, though I only soak my bum for a couple of minutes at a time.
All for now, and once again, welcome!

Savaici:
I have a friend that may have to have hemorrhoid surgery. Was it really that bad?

savaici wrote:Is the doctor that you saw a colon and rectal surgeon(CRS)?

Yes.

Hydrocortisone is for very short-term use for hemorrhoids and does nothing for fissures

More support for my believe that my pain is from some kind of inflammation (not muscle spasm) and my anal fissure is not directly relevant to the severe pain.

There is a lot of information on the forum.

From what I have read, my results from hydrocortisone are very different. I'm trying to either confirm that and get some better guess of what condition I actually have, or contradict that (others had similar experiences) and find out what to expect next.

Really glad that you have found some relief in the evenings, and long may it continue.

Maybe I was unclear. The one hydrocortisone suppository at bedtime 100% suppressed the symptoms for the full 24 hours until the next bedtime, for the first seven or eight days. After that, I have had a tiny fraction of the previous pain returning in the afternoon each day (and not after a BM).
If hydrocortisone were that dramatic a treatment for anal fissure, then it would be THE treatment. If it is that effective a treatment for whatever I actually have, then I should just be happy about it. But I am expecting it is just a short term symptom supression for what I actually have and I'd like to know what the illness is and what a long term treatment might be.
The doctor said that anal fissure is the cause of the majority of all cases of severe anal pain. That medical belief (whether correct or incorrect) will lead to misdiagnosis of other causes of severe anal pain as due to anal fissure, as I think has happened in my case. If others have been similarly mis diagnosed, maybe they can give me some idea of what the actual condition might be.

Hopefully someone will reply who can equate their symptoms with yours, but I would also suggest you ask your CRS these questions.
Good luck!

Yes! But, that was back then and I believe that there are easier methods now. I would not have it again, however

thisfissurecankissmybutt wrote:Savaici:
I have a friend that may have to have hemorrhoid surgery. Was it really that bad?

j65
have you had any thorough ivestigations suggested for you? Your pain seems to be a bit complex and could certainly be being caused by a multitude of different things, and it seems like in your case some more thorough investigation could be warranted.

I'm thinking specifically about ruling out inflammatory bowel disease that has settled only in your anorectal area. Not all cases of IBD involve the entire GI tract. I'm also wondering if you've ever been tested for any food sensitivities, and in particular for gluten intolerance. I'm also wondering about potential yeast problems in the area causing inflammatory problems.
Hydrocortisone can help some people with the pain of an average fissure. After all, the fssure is a cut which is going to go through the inflammatory stages of healing, and calming the inflammation also can calm the pain. It is really only a good idea for short term use if it is working or you, but since the description of your symptoms seem a bit more complex, it would probably be a good idea to explore some other avenues of investigation to get to the root cause of your pain.