Survival guide to chronic fissures

So after living with recurring fissures for the last 20 years of my life and just recently getting them under pretty good control, I'd like to share my own best practices to help all fellow sufferers out there.

Understanding the problem: your anatomy and psychology
The first place I went wrong was thinking that the problem was my stool. I have been constipated all my life, so I always thought something was wrong with my colon - that it reabsorbed too much water, thereby creating hard stools and causing frequent, recurring fissures. It wasn't until my last flare up that I dug deeper into this topic and realized that the problem is my anus - specifically, the sphincter muscles. We have 2 sphincter muscles: internal and external. We can control the external; the internal is involuntary smooth muscle (and also where the fissures reside). The fundamental problem for people with fissures is that the internal sphincter is too tight. The tightness makes the skin more prone to tearing, and also makes it much more difficult for torn skin to heal as it reduces blood flow to the area. All "solutions" to fissures, whether surgical or not, ultimately address the tightness issue, and help it relax.

It goes without saying then, that a big part of the tightness is psychological, and involves how you think about your anus. All my life, I thought stool, the anus, and that whole area of the body is super gross. I didn't want to think about it, so I would just ignore the pain and hope that it would heal. I've since learned that this is totally the wrong attitude, and probably the cause of most of my suffering. I now really appreciate my anus (I mean, elimination is literally vital to our existence), and I've developed much more comfort with the area - touching it, trying out suppositories, etc. So in short, love your anus, and it will maybe start to love you back!

Healing active fissures
Despite all the care I've taken to change my diet and keep my stool soft, I just had the worst flare up of my life, due to undergoing anesthesia for a surgery, which completely shut down my bowels for 4 days and created the hardest stool I've ever experienced. I'm proud of the fact that this was the fastest I've ever healed a fissure despite its severity, so here are my tips:

1. Topical nifedipine 0.2% (or something similar) FOUR TIMES A DAY to keep the internal sphincter relaxed, so it can heal faster. I've read mixed advice on applying it outside vs. inside and tried both, but feel like I had better results with inside application. The key point here is that it needs to be absorbed by your internal sphincter so it can relax and more blood can flow to the area. It does not need to directly on the fissure, as it does nothing for the wound itself. So in the early days when the pain was really bad, I'd take a q tip, put a pea-size dab of ointment, stick it inside past the fissure itself, and rotate around.
2. Keep stool soft to minimize additional trauma, during healing, and go as little as possible, but not so infrequently that your stool turns hard (for me that means still going once a day). I'd also apply a good dab of vaseline before each BM with a Q tip, to make things a bit more lubricated. I've seen some other people say they just do a water fast so as to not go at all, which sounds like a good idea if you can tolerate it. In my case, since I was also recovering from surgery, I needed food, but I stayed on a mostly liquid diet, with some high fiber vegetables like sweet potatoes and fruit/veggie smoothies, and I drank tons of water and took Colace twice a day. Of course, no matter how soft it is, it will still cause pain each time you go, until some healing happens. This is where the psychological relaxation part comes in.
3. Relaxing into the pain - this was a new strategy I tried, and it worked wonders. Usually when I'm experiencing a new/reopened fissure, I absolutely dread using the bathroom and my entire body is clenched super tight during the initial pass, as I anticipate the pain and just quickly push out the stool to get it all over with asap. This is actually super counterproductive. What I did this time was super slow anal Kegels 2-3x/day for a few minutes each time, where I felt like I had better and better control of my sphincter with each practice session. Then when I actually went for a BM, I took deep breaths and kept Kegeling for a few mins on the toilet bowl, almost like a warmup for the BM. Each time I'd let it stretch a bit bigger, and when there would inevitably be pain, I'd stay relaxed and breathe deeply, into the pain. I found that when I did this, the pain would actually go away after a few seconds. Then I'd contract back up again, relax, etc., and by the time I felt ready for the BM to pass, it would pass and not hurt! It literally brought me tears of joy the first time this happened, lol. I think the contracting and relaxation also helped soften up the stool as well.
4. Visualize your internal sphincter relaxing - I'm not sure how much of a role this actually played, but I'm sure it helped. Basically each night before sleeping, I would try to visualize my internal sphincter relaxing and staying relaxed, in the effort to program my subconscious sleeping self to stay relaxed in that area all night and speed up healing.
5. Using suppositories to help the skin heal - keeping the muscle relaxed to promote blood flow is the most important element of healing, but the skin itself could naturally use some help as well. I found some suppositories online called Proktis-M which has hyaluronic acid and other healing ingredients, and after a few days when the pain had subsided, I felt ok enough to push these suppositories in to promote faster healing. I'd apply the nifedipine first for it to absorb/relax the muscle, then put in the suppository just before sleeping so it could work its magic overnight. The Proktis-M I got also came kind of melted and the shape got messed up, so it wasn't super user friendly and I'm about to try making my own suppositories with coconut oil.
6. Minimize toilet time - during my flare up, because I had been bearing down so hard during the initial triggering incident, my entire rectum/anal canal was super inflamed. I probably had internal hemorrhoids in addition to the multiple fissures and general swelling. Sitting on the toilet makes all these things worse, so I'd really try to keep me BMs to less than 5 mins and get up immediately when done.
7. KEEP GOING FOR 4-8 WEEKS - this is another thing I used to do wrong. I thought that when the pain was gone, the healing was done. But apparently, pain is only the first thing that goes away, and the fissure is very much still there! Everything I mentioned here, I intend to keep doing for 8 weeks, even though my pain went away completely after 5 days.

Preventing future fissures
For the past few years, I've managed to find a routine that keeps my stool soft, and this has worked wonders. However, it's made traveling very difficult, and I realize now that I was not addressing the root issue (sphincter muscle tightness), only avoiding it. A healthy anus should be flexible, and once I'm fully healed this time, I intend to start physical therapy to slowly stretch it out and regain flexibility, even with all the scar tissue. I believe this is possible, as I've heard stories of people never getting fissures again post sphincterotomy (where they cut a part of the internal sphincter so that the entire muscle stays more relaxed permanently), which presumably means that full healing and regaining flexibility IS possible!

1. Keep stool soft - this, of course, is still the top priority, but again, it's more of a band-aid fix than a real solution. For me, having a smoothie every evening made of celery, carrot, apple, kiwi, banana, and a bit of water works beautifully. Other foods that have help me keep my GI system on track are sweet potatoes, wood ear mushroom, apricots, mild spice, and coffee (this triggers my daily BM). Of course, staying hydrated throughout the day, and especially in the morning, is key.
2. Anal dilation - I found this tip on this community, and it makes so much sense. Though I haven't tried it, I definitely intend to start after I'm fully healed. Basically you use a lubricated finger to massage and slowly stretch out the anus, and can even consider keeping dilators/plugs in it for 15 mins or so each day to keep the area relaxed and stretched out. My new understanding is that my internal sphincter has been totally traumatized by the recurring fissures, and it has PTSD, which keeps it overly contracted all the time, even during BMs. The goal is to teach it to relax, gently and over time, and retrain it to be flexible again.
3. Kegels - I don't think it ever hurts to gain greater control over your muscles, so this is something I intend to keep doing indefinitely.

I hope this advice is helpful for others out there, and if you have any additional tips, I would love to hear them! This condition is literally the WORST, and I find that it is so misunderstood especially by primary care docs (who all dismiss it as hemorrhoids), but with the right knowledge and practices, we CAN heal!