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 .
A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure
BACKGROUND Anal fissure is most commonly treated surgically by internal anal sphincterotomy . However , there is some concern over the effects of this procedure on continence . Nitric oxide donors such as glyceryl trinitrate ( GTN ) have been shown to cause a reversible chemical sphincterotomy capable of healing fissures in a small series of cases . This study reports a prospect i ve , r and omised , double-blind , placebo-controlled trial to test the hypothesis that topical GTN is the best first-line treatment for chronic anal fissure . METHODS 80 consecutive patients were r and omised to receive treatments with topical 0.2 % GTN ointment or placebo .  Maximum anal resting pressure ( MARP ) was measured with a constantly perfused side-hole catheter before and after the first application of trial ointment . Anodermal blood flow was measured during manometry by laser Doppler flowmetry . After initial treatments , patients were given a supply of ointment ( either GTN or placebo ) to be applied to the lower anal canal twice daily . Patients were review ed 2-weekly . At the initial and follow up visits patients were asked to record pain experienced on defaecation on a linear analogue pain score . Endpoints were healing of the fissure or condition after 8 weeks of treatment . FINDINGS After 8 weeks , healing was observed in 26/38 ( 68 % ) patients treated with GTN and in 3/39 ( 8 % ) patients treated with placebo ( p < 0.0001 , chi 2 test ) . Linear analogue pain score fell significantly in both groups after 2 weeks of treatment . This fall was maintained in those treated with GTN but pain scores returned to pre-treatment values by 4 weeks on treatment with placebo .  MARP fell significantly from a mean of 115.9 ( SD 31.6 ) to 75.9 ( 30.1 ) cm H2O ( p < 0.001 , Student 's paired t-test ) in patients treated with GTN but no change was seen in MARP after placebo .  Anodermal blood flow measured by laser Doppler flowmetry significantly increased after application of GTN ointment but was unaffected by placebo . INTERPRETATION Topical GTN provides rapid , sustained relief of pain in patients with anal fissure . Over two-thirds of patients treated in this way avoided surgery which would otherwise have been required for healing . Long-term follow up is needed to assess the risk of recurrent fissure in patients with GTN
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 .