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 .
Internal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure
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
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 .