Lateral sphincterotomy compared with anal advancement flap for chronic anal fissure The effect of topical nifedipine in treatment of chronic anal fissure. A Study of Fecal Incontinence in Patients with Chronic Anal Fissure: Prospective, Randomized, Controlled Trial of the Extent of Internal Anal Sphincter Division During Lateral Sphincterotomy A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. Comparative Study of Glyceryl Trinitrate Ointment Versus Surgical Management of Chronic Anal Fissure Botulinum toxin injection versus lateral internal sphincterotomy for the treatment of chronic anal fissure: randomized prospective controlled trial Lack of effficacy of botulinum toxin in chronic anal fissure A Comparison of the Effects of Diltiazem and Glyceryl Trinitrate Ointment in the Treatment of Chronic Anal Fissure: A Randomized Clinical Trial Long-term results of topical nitroglycerin in the treatment of chronic anal fissures are disappointing Faecal incontinence in patients with anal fissure: a consequence of internal sphincterotomy or a feature of the condition? [Mucosa advancement flap anoplasty in treatment of chronic anal fissures: a prospective, multicenter, randomized controlled trial]. Chronic anal fissures treated with botulinum toxin injections: a dose‐finding study with Dysport® Glyceryl trinitrate for chronic anal fissure—Healing or headache? A randomized trial of glyceryl trinitrate ointment and nitroglycerin patch in healing of anal fissures Anterior Levatorplasty for the Treatment of Chronic Anal Fissures in Females With a Rectocele: A Randomized, Controlled Trial Topical diltiazem vs. topical glyceril trinitrate in the treatment of chronic anal fissure: a prospective, randomized, double-blind trial. A prospective, randomized, double-blind, placebo-controlled trial of glyceryl-trinitrate ointment in the treatment of children with anal fissure. Pneumatic Balloon Dilatation for Chronic Anal Fissure: A Prospective, Clinical, Endosonographic, and Manometric Study Internal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure Randomised Prospective Controlled Trial of Topical 2 % Diltiazem Versus Lateral Internal Sphincterotomy for the Treatment of Chronic Fissure in Ano Topical diltiazem hydrochloride and glyceryl trinitrate in the treatment of chronic anal fissure. Randomized, prospective trial comparing 0.2 percent isosorbide dinitrate ointment with sphincterotomy in treatment of chronic anal fissure: A two-year follow-up Clinical, Manometric, and Ultrasonographic Results of Pneumatic Balloon Dilatation vs. Lateral Internal Sphincterotomy for Chronic Anal Fissure: A Prospective, Randomized, Controlled Trial
PURPOSE : This study was design ed to assess differences between lateral internal anal sphincterotomy and anal advancement flap for chronic anal fissure . METHODS : Forty patients with chronic anal fissure were prospect ively studied . Patients r and omized to the sphincterotomy group ( n=20 ; median age , 34 ( range , 16–61 ) years ) underwent lateral internal anal sphincterotomy . Patients r and omized to the  flap group ( n=20 ; median age , 32 ( range , 20–44 ) years ) had an anal advancement flap . RESULTS : All fissures in the sphincterotomy group healed following surgery compared with three patients that failed to heal in the flap group ( P= 0.12 ) . No patient in either group was incontinent to any degree following surgery . Patient satisfaction with surgery was similar in both groups . CONCLUSION : Anal advancement flap is an alternative to lateral sphincterotomy for chronic anal fissure Chronic anal fissure is the most common cause of anal pain associated with internal anal sphincter hypertonia . Reduction of hypertonocity is a special treatment for fissure healing . For this purpose chronic anal fissures were conventionally treated by anal dilatation or by lateral sphincterotomy . However , both of these methods may cause a degree of incontinence in some patients . The uptake of medical therapies that create a reversible chemical sphincterotomy has recently become widespread . The aim of this prospect i ve clinical trial study was to assess the effectiveness of nifedipine  in healing anal fissure , a calcium channel blocker that reduces sphincter pressure . A single-blind r and omized comparative trial was setup to compare traditional treatment with stool softeners and 2 % lidocaine cream against 0.5 % nifedipine cream for 4 weeks . 110 patients were included in this study , 60 patients in the nifedipine group and 50 patients in the control group and the therapeutic outcome and side effects were recorded . Healing had occurred in 70 % of patients in the nifedipine group and in 12 % of patients in the control group after 4 weeks treatment ( P < 0.005 ) . Recurrence of symptoms occurred in four of healed patients in the nifedipine group and three patients in the control group in two months . The final result of nifedipine application after 12 months follow up was recurrence in 11 patients ( 26.19 % ) . Mild headache occurred in four patients ( 6.6 % ) of the nifedipine group . Patients in the nifedipine group showed significant healing and relief from pain compared with patients in the control group . Recurrence rate with nifedipine use in spite of control of predisposing factors such as constipation was significant . Another finding was low complication rate with this treatment Background Troublesome fecal incontinence following a lateral internal sphincterotomy is often attributed to faulty surgical technique . However , it may be associated with coexisting occult sphincter defects . Whether continence is related to the extent of sphincterotomy remains debatable . The aim of the study is to identify fecal incontinence related to chronic anal fissure before and after lateral internal sphincterotomy and its relationship to the extent of internal anal sphincter division . Methods One hundred eight patients with chronic anal fissure were prospect ively studied before and after lateral internal sphincterotomy . A question naire was completed for each patient before and after surgery with regard to any degree of fecal incontinence . Fecal incontinence severity index was assessed using the Clevel and Clinic Incontinence Score .  The patients with preoperative perfect continence were r and omized into two groups ( 46 patients in each group ) : Group 1 underwent traditional lateral internal sphincterotomy ( up to the dentate line ) and Group 2 were underwent a conservative internal anal sphincterotomy ( up to the height of the fissure apex or just below it ) . Results Minor degrees of incontinence were present before surgery in 16 patients ( 14.8 % ) . Results of the r and omized trial revealed that temporary postoperative incontinence was newly developed in 6/92 of patients ( 6.52 % ) who did not have it before surgery . Five of the six ( 10.86 % ) were in Group 1 one ( 2.17 % ) was in Group 2 ( p = 0.039 ) . Persistent incontinence occurred in two in Group 1 ( 4.35 % ) . All of them were females . All have had a history of one or more vaginal deliveries .  Conclusion A mild degree of fecal incontinence may be associated with chronic anal fissure at presentation rather than as a result of internal sphincterotomy . Troublesome fecal incontinence after lateral internal sphincterotomy is uncommon . Sphincterotomy up to the dentate line provided faster pain relief and faster anal fissure healing , but it was associated with a significant postoperative alteration in fecal incontinence than was sphincterotomy up to the fissure apex . Care should be exercised in female patients with a history of previous obstetric trauma , as internal anal sphincter division may further compromise sphincter function BACKGROUND AND METHODS Lateral internal sphincterotomy , the most common treatment for chronic anal fissure , may cause permanent injury to the anal sphincter , which can lead to fecal incontinence . We compared two nonsurgical treatments that avert the risk of fecal incontinence . We r and omly assigned 50 adults with symptomatic chronic posterior anal fissures to receive treatment with either a total of 20 U of botulinum toxin injected into the internal anal sphincter on each side of the anterior midline or 0.2 percent nitroglycerin ointment applied twice daily for six weeks . RESULTS After two months , the fissures were healed in 24 of the 25 patients ( 96 percent ) in the botulinum-toxin group and in 15 of the 25 ( 60 percent ) in the nitroglycerin group ( P=0.005 ) . No patient in either group had fecal incontinence . At some time during treatment , five patients in the nitroglycerin group had transient , moderate-to-severe headaches that were related to treatment . None of the patients in the botulinum-toxin group reported adverse effects . Ten patients who did not have a response to the assigned treatment - 1 in the botulinum-toxin group and 9 in the nitroglycerin group - crossed over to the other treatment ; the fissures subsequently healed in all 10 patients . There were no relapses during an average of about 15 months of follow-up . CONCLUSIONS Although treatment with either topical nitroglycerin or botulinum toxin is effective as an alternative to surgery for patients with chronic anal fissure , botulinum toxin is the more effective nonsurgical treatment Chronic Anal Fissure ( CAF ) is common perineal condition and well-known painful entity . St and ard surgical treatment even though available , may require long hospital stay and sometimes have worrying complications like anal incontinence . So non-surgical treatment , Glyceryl Trinitrate has been shown to be an effective for chronic anal fissure . It decreases anal tone and ultimately heals the anal fissure . The present study is the attempt to know the efficacy of 0.2 % Glyceryl Trinitrate ointment in the treatment of chronic anal fissure and to compare the effectiveness of 0.2 % Glyceryl Trinitrate ointment ( GTN ) versus fissurectomy with lateral internal sphincterotomy ( LIS ) and fissurectomy with posterior internal sphincterotomy ( PIS ) in the management of chronic anal fissure . This is a prospect i ve comparative study of management of chronic anal fissure done in our hospital during the period of one and half year from October 2005 to March 2007 . Thirty patients treated with 0.2 % Glyceryl Trinitrate ointment and 30 patients treated with fissurectomy and lateral internal sphincterotomy and 30 patients treated with posterior internal sphincterotomy , for chronic anal fissure were selected for study . A single br and of 0.2 % Glyceryl Trinitrate ointment ( Nitrogesic ) used for trial arm . Dose of administration was 1.5 cm to 2 cm in the anal canal with device provided by manufacturers of the proprietary preparation and applied twice a daily for 12 weeks . Patients were followed up for 12 weeks and thereafter evaluated for relief of symptoms in all three groups . Observations were recorded at 2 weeks ; 6 weeks and 12 weeks of follow up period , regarding symptoms like pain and bleeding during defecation , healing of CAF and also for side effects like headache in GTN group and flatus , fecal incontinence in surgical groups . Data collected in proforma and analyzed . Study revealed CAF was more in male 59 patients ( 66 % ) than the female 31 patients ( 34 % ) , the ratio being 1 : 0.52 . The maximum number of patients was encountered in the age group of 20 to 40 years with mean duration of age 34.14 years . In all three groups symptoms like pain , bleeding , constipation and sphincter spasm were present . Sentinel pile was present in 56 % of the patients . Common site of fissure was found to be posterior in 94 % of patients . Observations with respect to relief of pain , no bleeding and healing were recorded at 2 , 6 and 12 weeks of duration . Lateral sphincterotomy remains effective but should be reserved for the patients who fail to respond to initial chemical sphincterotomy or GTN therapy . GTN is good alternative mode of therapy for patients who refuse surgery and prefer medical line of treatment Purpose Lateral internal sphincterotomy has been the gold st and ard treatment for chronic anal fissure , but it still carries the risk of permanent damage of the anal sphincter , which has led to the implementation of alternative treatment like botulinum toxin injection . The aim of this r and omized prospect i ve controlled trial was to compare the efficacy and morbidity of botulinum toxin injection and lateral internal sphincterotomy in the treatment of chronic anal fissure . Methods Fifty consecutive adults with chronic anal fissure were r and omly treated with either lateral internal sphincterotomy or botulinum toxin ( BT ) injection with 50 U BT into the internal sphincter . The complications , healing and recurrence rate , and incontinence score were assessed 2 , 3 , 6 , 12 months after the procedure . Results Inspection at the 2-month visit revealed complete healing of the fissure in 11 ( 44 % ) of the patients in the BT group and 22 ( 88 % ) of the patients in the lateral internal sphincterotomy ( LIS ) group ( p = 0.001 ) . At the 3-month visit , there was no significant difference between the two groups in healing . The overall recurrence rate after 6 months in the BT group was higher than in the LIS group ( p < 0.05 ) . In the 3-month follow-up , the LIS group had a higher rate of anal incontinence compared to the BT group ( p < 0.05 ) . The final percentage of incontinence was 4 % in the LIS group ( p > 0.05 ) . Conclusions The treatment of chronic anal fissure must be individualized depending on the different clinical profiles of patients . Botulinum toxin injection has a higher recurrence rate than LIS , and LIS provides rapid and permanent recovery . However , LIS carries a higher risk of anal incontinence in patients Background and aim : Hypertonicity of internal anal sphincter plays a major role in the persistence of chronic anal fissure .  Botulinum toxin could induce internal anal sphincter relaxation without the adverse effects of surgery ( long‐term faecal incontinence ) or topical nitrates  ( anal burning , headaches , hypotension ) Purpose Anal fissure is a common problem affecting all age groups with an equal incidence in both sexes . Traditional surgical treatments , like manual anal dilatation or a sphincterotomy , effectively heal most fissures within a few weeks but such procedures may result in anal incontinence . In recent years , various medical therapies have been used for the treatment of chronic anal fissure without fear of incontinence . Methods Ninety patients with a symptomatic anal fissure were r and omly divided into three groups . Group I was treated with 2 % diltiazem ointment , Group II was treated with 0.2 % glyceryl trinitrate ( GTN ) ointment , and Group III was kept as the control group . The improvement in the signs and symptoms , the time taken for healing , and side effects were recorded in each group . The patients were followed up monthly and then every 3 months for any recurrence of fissure . Comparative evaluations of the three groups regarding an improvement in symptoms , progress in healing , appearance of side effects , and recurrence were made using the Tukey HSD test . Results Diltiazem ointment was found to be superior regarding pain relief , fewer side effects , and late recurrence as compared with GTN ointment . Conclusion Diltiazem ointment ( 2 % ) and GTN ointment ( 0.2 % ) are both effective treatment modalities for chronic anal fissure , with diltiazem giving better patient outcome Several treatments for anal fissure offer different responses and risks for complications . Reversible chemical sphincterotomy with topical nitroglycerin is an alternative to surgical sphincterotomy . The aim of this observational prospect i ve study was to compare the effectiveness of topical nitroglycerin with the conventional medical treatment . Forty-three patients with anal fissure were treated : 22 ( 16 chronic and 6 acute ) received 0.25 % nitroglycerin topically , and 21 ( 16 chronic and 5 acute ) received conventional treatment . Nitroglycerin or placebo was administered in two daily applications for two weeks . Median follow-up was 39 weeks . Healing rate with NTG was 75 % for chronic and 83 % for acute fissures , but recurrence rate for chronic fissures at 9 months was 67 % . Healing rate with placebo for chronic fissures was only anecdotical ( 1 out of 16 patients ) . Headache as side effects occurred in 17 cases ( 77 % ) . In conclusion , both treatments were effective for acute fissures , whereas for chronic ones NTG had a high healing rate but also a high recurrence rate BACKGROUND AND OBJECTIVE The function of the internal sphincter is disturbed in patients with chronic anal fissure due to persistent hypertonia and it may lead to a certain degree of incontinence . Our aim is to assess the results of lateral internal sphincterotomy and to identify any degree of incontinence related to the disease . METHODS This prospect i ve study included a review of all patients operated upon by the authors who performed division of the internal sphincter at or below the upper limit of the fissure .  A question naire was completed by each patient before surgery and then after surgery with regard to any degree of incontinence such as soiling of underclothes , control of flatus and accidental bowel motion . RESULTS 126 patients with chronic anal fissure were studied . The male to female ratio was 0.8:1 . Minor degrees of incontinence were present prior to surgery in 35 patients ( 28 % ) and in 31 ( 25 % ) patients after surgery , the majority of them were incontinent before surgery . CONCLUSION Based on the results of this study , minor degrees of incontinence could be a symptom of chronic anal fissure and not the sequelae of lateral internal sphincterotomy BACKGROUND Anal fissure is one of the most common anal-rectum diseases , and approximately 10 percent patients with chronic anal fissure ultimately receive surgery . Relieving postoperative pain and protecting functions of the sphincter are central issues for coloproctologists . OBJECTIVE To evaluate the efficacy and safety of anoplasty in the treatment of chronic anal fissures . DESIGN , SETTING , PARTICIPANTS AND INTERVENTIONS In this prospect i ve , multicenter , r and omized controlled trial , 120 adult patients with chronic anal fissure were referred from Department of Coloproctology of Yueyang Hospital of Integrated Traditional Chinese Medicine Affiliated to Shanghai University of Traditional Chinese Medicine , Shanghai Ninth People 's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine and Shanghai Municipal Hospital of Traditional Chinese Medicine . The patients were enrolled from January 2009 to April 2010 and r and omly divided into study ( mucosa advancement flap anoplasty , abbreviated as anoplasty ) group and control ( fissurectomy ) group . The two groups were assessed separately , and the main outcome measures were observed for 2 weeks , with a short-term follow-up for 6 weeks . MAIN OUTCOME MEASURES Degree of pain , haemorrhage and anal canal pressure were observed and recorded preoperatively , and on the third day , the fourteenth day and the sixth week postoperatively . The wound healing time was also recorded . Surgical complications of the two groups were recorded and compared on the third day and the sixth week postoperatively . The curative effects associated with the surgery were analyzed on the fourteenth day and the sixth week after surgery and the therapeutic results were evaluated . RESULTS Three patients were dropped out due to the early discharge from hospital and losing connection ( 1 in study group and 2 in control group ) . Overall the surgery showed that the anoplasty group had better results than the fissurectomy group in the curative effect on the sixth week after operation ( P<0.05 ) . Time of wound healing in the anoplasty group was ( 17.22 ± 4.41 ) d and was better than ( 21.24 ± 7.44 ) d of the fissurectomy group ( P<0.05 ) . Concerning the relief of wound pain , the anoplasty group achieved better results than the fissurectomy group at the third day , the fourteenth day and the sixth week after operation ( P<0.05 ) . Anoplasty reduced bleeding and had better efficacy than the fissurectomy at the third day and the fourteenth day after operation ( P<0.05 ) , however , there was no statistical difference at the sixth week after operation ( P>0.05 ) . There were no significant differences in relieving the anal canal pressure ( P>0.05 ) and the surgical complications ( dysuria , edema of anal margin , fever , infection , anal incontinence and anal deformation ) between the two groups ( P>0.05 ) . None of the patients suffered postoperative complications by the sixth week after operation . Furthermore , there was no recurrence in either of the two groups at six weeks after operation . CONCLUSION The results indicate that anoplasty for chronic anal fissures has advantages such as better therapeutic effects , less postoperative pain , a shorter healing time and no incidence of anal incontinence Botox ® injection of the anal sphincter muscle cures  chronic uncomplicated anal fissures in up to 80 % of patients . This study examines the therapeutic efficacy and side effect profile of the British botulinum product Dysport ® .  Fifty patients ( 29 women ) were recruited to participate in this r and omized dose‐finding study , their mean age being 32.9 years . The low dose group A was treated with a total dose of 20 U injected in two sites each lateral to the fissure , the high dose group B was treated with 40 U. Eighty‐two percent of patients were pain‐free within a week following the injections . The fissure was healed in 78 % of treated patients after 3 months . Three patients relapsed within 6 months . The most common adverse side effect was transient incontinence ( n = 4 ) . Clinical outcome was not significantly different between the two treatment groups . The low dose can therefore be regarded sufficient for the treatment of anal fissure . Therapeutic efficacy was equivalent to published data on Botox treatment . Both Dysport ® and Botox ® can therefore be used to treat chronic uncomplicated anal fissures . Both Dysport ® and Botox ® therapy are well tolerated , can be performed on an out‐patient basis and avoid the risk of permanent faecal incontinence which complicates surgical treatment of anal fissures PURPOSE : Internal anal sphincterotomy for treating chronic anal fissure can irreversibly damage anal continence . Reversible chemical sphincterotomy may be achieved by anal application of glyceryl trinitrate ointment ( nitric oxide donor ) , which has been reported to heal the majority of patients with anal fissure by inducing sphincter relaxation and improving anodermal blood flow . This trial aim ed to further clarify the role of glyceryl trinitrate in the treatment of chronic anal fissure . METHODS : A total of 132 consecutive patients from nine centers were r and omly assigned to receive 0.2 percent glyceryl trinitrate ointment or placebo twice daily for at least four weeks . The severity of pain and maximum anal resting pressure were measured before and after one week of treatment . Anodermal blood flow was measured before and after application of glyceryl trinitrate or placebo in ten patients . RESULTS : The study was completed by 119 patients ( 59 glyceryl trinitrate and 60 placebo ) , matched for gender , age , duration of symptoms , duration of treatment , site of fissure , previous attempts to treat , pain score , and maximum anal resting pressure . Twenty-nine patients ( 49.2 percent ) healed after glyceryl trinitrate and 31 patients ( 51.7 percent ) healed after placebo ( P= not significant ) . Pain score fell significantly in both groups , in addition to maximum anal resting pressure . Anodermal blood flow improved significantly in seven patients receiving glyceryl trinitrate , but not in the three receiving placebo . Twenty-three patients ( 33.8 percent ) experienced headache and 4 ( 5.9 percent ) , orthostatic hypotension after glyceryl trinitrate . CONCLUSION : This trial fails to demonstrate any superiority of topical 0.2 percent glyceryl trinitrate treatmentvs . a placebo , although the effects of glyceryl trinitrate on anodermal blood flow and sphincter pressure are confirmed . This finding , together with the high incidence of side-effects , should discourage the use of this treatment as a substitute for surgery in chronic anal fissure Abstract . Mean maximum anal resting pressure is directly related to the activity of the smooth muscles of the internal and external sphincters and has been found to be increased in the patients of anal fissure . It has been shown that blood flow at the posterior midline of anoderm is inversely related to the mean maximum anal resting pressure , and topical application of glyceryl trinitrate ( GTN ) ointments is a very successful treatment . This r and omized study was design ed to evaluate the relative value of a nitroglycerin patch applied at a distance from the fissure site in healing anal fissure compared to GTN ointment and compared to surgical treatment .  Forty-two consecutive patients with chronic anal fissure of more than 4 months ' duration were r and omized into two equally sized groups : those in group A received 0.2 % GTN ointment while those in group B received a 10-mg nitroglycerin patch for 8 weeks . Patients were also asked to rate their pain intensity on a scale of 0–10 . Five patients were excluded for various reasons ; results were analyzed for the remaining 37 patients ( group A , n=18 ; group B , n=19 ) . A control group C consisted of 12 patients who underwent surgical treatment . Fissures healed completely in 12 of 18 ( 66.7 % ) patients in group A , 12 of 19 ( 63.2 % ) in group B and 11/12 ( 91.7 % ) in group C. The healing rates in groups A and B did not differ significantly ( P=0.7 ) , nor was there a difference between these and surgical group C ( P=0.13 ) . The local application of GTN ointment and the nitroglycerin patch are both effective , economical , and alternative treatment options for most patients with anal fissures PURPOSE : It is postulated that an anterior anal fissure can result from mucosal trauma occurring during distention of a rectocele and that repair of the rectocele by anterior levatorplasty can lead to healing of these anal fissures . This study was design ed to compare anterior levatorplasty with internal sphincterotomy for the management of anterior anal fissures in females with a rectocele . METHODS : From June 2000 until May 2002 , 54 consecutive females with an anterior anal fissure and a rectocele were r and omized to be managed by internal sphincterotomy or anterior levatorplasty . Preoperatively , manometry was performed , continence was measured using the Clevel and Clinic scoring system , pain scores were obtained using a visual analog scale , and the symptoms of bleeding and straining to defecate were assessed . Postoperatively , pain scores were obtained at Days 2 , 7 , and 21 . Manometry , continence scores , and resolution of symptoms were measured between 8 and 12 weeks . Patient satisfaction and fissure healing also were assessed between 8 and 12 weeks . The average length of follow-up was 20 ( range , 6–30 ) months . RESULTS : Postoperatively , lateral sphincterotomy caused a decrease in the resting pressures and anterior levatorplasty result ed in an increased length of the anal canal . Anterior levatorplasty also caused increased postoperative pain scores . There were no differences in fissure healing and patient satisfaction . CONCLUSIONS : These data suggest that anterior levatorplasty is an option for the management of patients with a rectocele , which may avoid the risk of incontinence with lateral internal sphincterotomy and better address the etiology of anterior anal fissures BACKGROUND AND STUDY AIMS Chemical sphincterotomy is a new way for the treatment of chronic anal fissure which avoids the risk of faecal incontinence associated with traditional surgical methods . The aim of this study was to compare topical Diltiazem with topical Glyceril trinitrate in the treatment of chronic anal fissure . PATIENTS AND METHODS 61 patients ( 10 Male , 51 Female ) between 16 - 81 years of age with chronic anal fissure were included in this prospect i ve , r and omized , double-blind trial . The patients were r and omly allocated to either Diltiazem gel ( 2 % ) or Glyceril trinitrate ointment ( 0.2 % ) and were asked to use the treatment twice daily for 8 weeks . Each patient was review ed every two weeks ; pain scores , healing and side effects were assessed . RESULTS Healing occurred in 33 of 36 ( 91.66 % ) patients treated with Diltiazem after 6 weeks and 15 of 25 ( 60 % ) patients treated with Glyceril trinitrate after 8 weeks which shows a significant difference in favour of Diltiazem ( P < 0.001 ) . The rest of the patients were either non-compliant or did not heal and underwent surgery . Headache occurred in all of the patients treated with Glyceril trinitrate but none of the patients treated with Diltiazem developed headache . The frequency of other side-effects was also less in patients treated with Diltiazem ( P < 0.001 ) . CONCLUSIONS Diltiazem gel was found to be superior to Glyceril trinitrate ointment due to significantly higher healing rate and fewer side-effects BACKGROUND Anal fissure in children usually is treated by sitz baths , stool softeners , and analgesic ointments . However , some cases are intractable to the treatment . In recent years , it has been reported that nitric oxide donors such as local glyceryl-trinitrate ( GTN ) ointment causes a reversible chemical sphincterotomy . Although the GTN ointment can be an alternative therapy for adult cases , it has not yet been studied in the children who suffer from anal fissure . METHODS Sixty-five children with anal fissure were divided r and omly into 3 groups . Each group received double-blinded a topical ointment that contained either 0.2 % GTN , 10 % lidocaine , or placebo . These ointments were applied to the lowest part of the anal canal twice daily . Patients were periodically review ed , and the study was ended after 8 weeks . RESULTS Complete healing of the fissure occurred in 26 of 31 ( 83.9 % ) patients treated with GTN , 7 of 14 ( 50 % ) patients treated with lidocaine , and 6 of 17 ( 35.2 % ) treated with placebo . In 29 of 31 ( 93.5 % ) GTN-treated patients , a total relief of symptoms was observed , whereas this occurred in 7 of 14 ( 50 % ) treated with lidocaine and 6 of 11 ( 35.3 % ) in the placebo group . The differences between the study group and control groups were highly statistically significant ( P < .001 ) . CONCLUSION The majority of children suffering from anal fissure will be cured and have relief of symptoms after topical application of GTN ointment to the anal canal PURPOSE Pneumatic balloon dilation has been shown to be effective in the management of  chronic anal fissure  , but its effect on the anal sphincter has not been fully investigated . The aim of this study was to evaluate prospect ively the clinical , anatomic , and functional pattern in a group of patients treated by pneumatic balloon dilation .  METHODS A series of 33 consecutive patients suffering from chronic anal fissure underwent pneumatic balloon dilation .  Anal manometry and ultrasonography were performed prior to and 6 to 12 months after the treatment . Manometry was accomplished by means of an endoanal 40-mm balloon inflated with a pressure of 1.4 atmospheres that was left in situ for six minutes under local anesthesia . All patients were interviewed daily for three days after surgery and then clinical ly evaluated between the third and fifth postoperative weeks . Most patients were interviewed after 25.7 ± 8.4 months ( mean ± st and ard deviation ) . Anal incontinence was evaluated by means of a vali date d score of 1 to 6 . RESULTS The chronic anal fissure healed between the third and fifth weeks in 31 patients ( 94 percent ) , who became asymptomatic 2.5 ± 1.4 days after pneumatic balloon dilation . None of them reported anal pain two years after the treatment ( n = 20 ) . The first post-pneumatic balloon  dilation defecation was painless in 27 cases ( 82 percent ) . Two multiparous females ( 6 percent of the patients ) complained of minor transient anal incontinence ( score , 3 ) . Chronic anal fissure recurred in one case ( 3 percent ) after treatment . At manometry , the preoperative anal resting pressure decreased from 91 ± 11.2 to 70.5 ± 5.6 and to 78 ± 5.7 mmHg , 6 and 12 months after pneumatic balloon dilation , respectively ( P < 0.0001 ) . Anal ultrasonography did not show any significant sphincter defect . CONCLUSIONS Pneumatic balloon dilation seems to be an effective , safe , easy procedure that decreases anal resting pressure without endosonographically detectable significant sphincter damage PURPOSE : This was a multicenter , r and omized , controlled trial to compare the effectiveness of topical nitroglycerin with internal sphincterotomy in the treatment of chronic anal fissure . METHODS : Patients with symptomatic chronic anal fissures were r and omly assigned to 0.25 percent nitroglycerintid or internal sphincterotomy . Both groups received stool softeners and fiber supplements and were assessed at six weeks and six months . RESULTS : Ninety patients were accrued , but 8 were excluded from the analysis because they refused internal sphincterotomy after r and omization ( 6 ) , the fissure healed before surgery ( 1 ) , or a fissure was not observed at surgery ( 1 ) . There were 38 patients in the internal sphincterotomy group ( 22 males ; mean age , 40.3 years ) and 44 patients in the nitroglycerin group ( 15 males ; mean age , 38.7 years ) . At six weeks 34 patients ( 89.5 percent ) in the internal sphincterotomy group compared with 13 patients ( 29.5 percent ) in the nitroglycerin group had complete healing of the fissure ( P=5 × 10−8 ) . Five of the 13 patients in the nitroglycerin group relapsed , whereas none in the internal sphincterotomy group did . At six months fissures in 35 ( 92.1 percent ) patients in the internal sphincterotomy group compared with 12 ( 27.2 percent ) patients in the nitroglycerin group had healed ( P=3 × 10−9 ) . One ( 2.6 percent ) patient in the internal sphincterotomy group required further surgery for a superficial fistula compared with 20 ( 45.4 percent ) patients in the nitroglycerin group who required an internal sphincterotomy ( P=9 × 10−6 ) . Eleven ( 28.9 percent ) patients in the internal sphincterotomy group developed side effects compared with 37 ( 84 percent ) patients in the nitroglycerin group ( P<0.0001 ) . Nine ( 20.5 percent ) patients discontinued the nitroglycerin because of headaches ( 8) or a severe syncopal attack ( 1 ) . CONCLUSIONS : Internal sphincterotomy is superior to topical nitroglycerin 0.25 percent in the treatment of chronic anal fissure , with a high rate of healing , few side effects , and low risk of early incontinence . Thus , internal sphincterotomy remains the treatment of choice for chronic anal fissure Fissure in ano is a very common disorder of the anorectal region . Internal sphincter hypertonia with decreased relaxation coupled with mucosal ischemia of posterior anal canal are the major pathologies in chronic anal fissure ( CAF ) . Though lateral internal sphincterotomy ( LIS ) remains the gold st and ard of treatment for the disease , it is accompanied by the potential complication of incontinence to both flatus and faecal matter . The aim of our study was to explore the role of topical diltiazem as an effective and a safe alternative to sphincterotomy for chronic anal fissure . Ninety patients with CAF were r and omly assigned to group A and group B , with 45 patients each . Group A patients received 2 % diltiazem topical application , twice daily , and group B patients underwent LIS . All the patients were review ed at first , fourth and sixth week after initiation of treatment . Visual analogue scores for pain and healing of fissure by visual inspection were recorded and compared . In group A , 71 % had complete healing of fissure at 6 weeks , with fair amount of pain relief ( mean VAS—3.38 ) , and in group B , 96 % showed healing of fissure , with excellent pain relief ( mean VAS—1.87 ) . Headache and flushing were noted in two patients in group A while no patients in group B developed incontinence . We conclude that LIS is more effective than topical diltiazem in the treatment of CAF . Topical diltiazem may be employed as an initial conservative treatment option before considering the surgical alternative OBJECTIVE To compare the symptomatic relief , healing and side-effects of topical diltiazem ( DTZ ) and glyceryl trinitrate in the treatment of chronic anal fissure .  STUDY DESIGN R and omized controlled trial . PLACE AND DURATION OF STUDY The Surgical Outpatient Department of Civil Hospital , Karachi , from March 2006 to February 2007 . METHODOLOGY Patients with chronic anal fissure were included in the study and r and omized to two groups . One group was administered topical 2 % diltiazem hydrochloride and other was given 0.2 % glyceryl trinitrate ( GTN ) , perianally twice daily for 8 weeks . Patients with anal fissure due to other diseases like inflammatory bowel disease , malignancy , sexually transmitted diseases , previous treatment with local ointment or surgery ; patients who required anal surgery for any concurrent disease like hemorrhoids , pregnant women and patients with significant cardiovascular conditions were excluded . There were four follow-up sessions during the course of treatment . Healing and side-effects were recorded . Analysis was done by SPSS version 10 on intention-to-treat basis . Chi-square was used where appropriate . RESULTS Eighty patients with symptomatic chronic anal fissure were included in the study and equally divided into two groups . After 8 weeks of treatment healing occurred in 31 of 40 patients treated with diltiazem and 33 of 40 patients treated with GTN ( p = 0.576 ) . There were less side-effects with DTZ ( n=13 ) than with GTN ( n=29 , p < 0.001 ] . In particular , headache occurred more commonly with GTN ( n=27 ) than with DTZ ( n=9 , p < 0.0001 ) . CONCLUSION Diltiazem hydrochloride and glyceryl trinitrate were equally effective in healing chronic anal fissure .  Diltiazem caused fewer side-effects particularly headache than glyceryl trinitrate ointment . Diltiazem may be the first-line treatment for chemical sphincterotomy for the chronic anal fissure Purpose : The aim of this trial was to compare lateral internal sphincterotomy with local 0.2 percent isosorbide dinitrate in the treatment of chronic anal fissure to minimize surgical complications such as minor fecal incontinence . Methods : Fifty-four patients with chronic anal fissure were r and omized in a prospect i ve trial to either sphincterotomy or local 0.2 percent isosorbide dinitrate . All patients had anal function tests before and 5 weeks after treatment . Results : In the ointment group , 18 patients ( 67 percent ) healed at 5 weeks and 24 ( 89 percent ) healed at 10 weeks of treatment . Maximum resting anal pressure was reduced 30 percent . Eight patients ( 30 percent ) had minor side effects . In the surgical group , 26 patients ( 96 percent ) healed at 5 weeks and 100 percent healed at 10 weeks after treatment , with 33 percent reduction in maximum resting anal pressure . Forty-four percent of patients had minor fecal incontinence , which remained in 15 percent after 24 months follow-up . No statistical difference in maximum resting anal pressure was found between groups ( P = 0.16 ) , but the percentage of healing at 5 weeks was greater in the surgical group ( P < 0.001 ) . Conclusions : Isosorbide dinitrate ointment must be considered as the first choice of treatment in patients with chronic anal fissure . Surgery should be indicated if chemical sphincterotomy fails Purpose This prospect i ve , r and omized , controlled trial was design ed to compare the clinical , functional , and morphologic results of pneumatic balloon dilatation with lateral internal sphincterotomy for the treatment of chronic anal fissure . Methods All patients with symptomatic chronic anal fissure were r and omly assigned to  pneumatic balloon dilatation or lateral internal sphincterotomy  and invited to complete a st and ardized question naire inquiring about their symptoms . Anal ultrasonography and anal manometry were performed before and six months after surgery . A proctologic examination was performed between the fifth and sixth postoperative weeks . Anal continence , scored by using a vali date d continence grading scale , was evaluated preoperatively at 1 and 6 weeks and at 12 and 24 months . Results Fifty-three patients , who satisfied selection criteria , were enrolled in the trial . Four patients ( 7.5 percent ) were lost to follow-up . Twenty-four patients ( 11 males ; mean age , 42 ± 8.2 years ) underwent pneumatic balloon dilatation and 25 patients ( 10 males ; mean age , 44 ± 7.3 years ) underwent lateral internal sphincterotomy . Fissure-healing rates were 83.3 percent in the pneumatic balloon dilatation and 92 percent in the lateral internal sphincterotomy group . Recurrent anal fissure was observed in one patient ( 4 percent ) after lateral internal sphincterotomy . At anal manometry , mean resting pressure decrements obtained after pneumatic balloon dilatation and lateral internal sphincterotomy were 30.5 and 34.3 percent , respectively . After pneumatic balloon dilatation , anal ultrasonography did not show any significant sphincter damage . At 24-month follow-up , the incidence of incontinence , irrespective of severity , was 0 percent in the pneumatic balloon dilatation group and 16 percent in the lateral internal sphincterotomy group ( P < 0.0001 ) . Conclusions As lateral internal sphincterotomy , pneumatic balloon dilatation grants a high anal fissure-healing rate but with a statistically significant reduction in postoperative anal incontinence
Botox and CCBs were equivalent to GTN in efficacy with fewer adverse events .
No medical therapy came close to the efficacy of surgical sphincterotomy , though none in these RCTs was associated with the risk of incontinence .
Medical therapy for chronic anal fissure , acute fissure and fissure in children may be applied with a chance of cure that is marginally better than placebo , and , for chronic fissure in adults , far less effective than surgery
BACKGROUND Because of the disability associated with surgery for anal fissure and the risk of incontinence , medical alternatives for surgery have been sought .
Most recently , pharmacologic methods that relax the anal smooth muscle , to accomplish reversibly what occurs in surgery , have been used to obtain fissure healing .
OBJECTIVES To assess the efficacy and morbidity of various medical therapies for anal fissure .