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 .
Glyceryl trinitrate ointment for the treatment of chronic anal fissure
PURPOSE : A r and omized , double-blind , placebo-controlled trial was performed to test the effect of intra-anal glyceryl trinitrate ointment in patients with chronic anal fissures that would normally have been treated by sphincterotomy . Long-term follow-up was then performed to assess fissure healing . METHODS : Patients with chronic anal fissures were r and omly assigned to 0.2 percent topical glyceryl trinitrate ointment or placebo . Anal manometry was performed before treatment , one week later , and 48 hours after treatment ceased at four weeks . Fissure healing was assessed by an observer blinded to the treatment arm . Pain was recorded on a linear analog scale . At the completion of the trial , treatment was continued with glyceryl trinitrate until fissure healing was obtained or lateral sphincterotomy was performed if required for ongoing pain . A long-term follow-up assessment was made at a mean of 29 ( range , 25–33 ) months . RESULTS : There was a significant reduction in anal resting pressure at Week 1 with glyceryl trinitrate ( P=0.001 ) but not placebo , and at Week 4 there was a significant reduction in pain score with glyceryl trinitrate ( P=0.001 ) and placebo ( P=0.01 ) and a significant reduction in fissure grade with glyceryl trinitrate ( P=0.0001 ) and placebo ( P=0.02 ) . Forty-six percent of fissures healed with glyceryl trinitrate and 16 percent healed with placebo ( P=0.001 ) . At long-term follow-up in 40 of 43 patients , 14 patients ( 35 percent ) had undergone lateral sphincterotomy , and in the remainder who were treated with glyceryl trinitrate there was a significant reduction in pain score ( P=0.0002 ) . Seventeen patients attended for repeat manometry and fissures were healed with glyceryl trinitrate in ten ( 59 percent ) cases . High internal sphincter pressures persisted at long-term follow-up in patients successfully treated with glyceryl trinitrate , indicating that the sphincter is the cause rather than effect of anal fissure . CONCLUSION : Topical glyceryl trinitrate produces a successful internal sphincterotomy , which result ed in long-term healing of 59 percent of chronic anal fissures and significant improvement in pain . Internal sphincter spasm is the cause of chronic anal fissure
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 .