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 randomized trial of oralvs. topical diltiazem for chronic anal fissures
INTRODUCTION : Chemical sphincterotomy has proved effective in treating chronic anal fissure .  Glyceryl trinitrate is the most widely used agent , and topical 0.2 percent glyceryl trinitrate ointment heals up to two thirds of chronic anal fissures . Unfortunately , however , many patients experience troublesome headaches as a side effect of this treatment . This study assessed the effectiveness of oral and topical diltiazem in healing chronic fissures . METHODS : Fifty consecutive patients with chronic anal fissures were r and omly assigned to receive oral ( 60 mg ) or topical ( 2 percent gel ) diltiazem twice daily for up to eight weeks . Anal manometry was performed before and after the first dose , and blood pressure was recorded at 15-minute intervals . Patients were review ed fortnightly , pain was expressed with a visual linear analog scale , blood pressure was recorded , fissure healing was assessed , and side effects were noted . RESULTS : Twenty-four patients received oral diltiazem , and 26 received topical diltiazem . Mean ( ± st and ard error of the mean ) maximum resting anal pressures fell by 15 and 23 percent from 95±4 to 81±4 and from 102±5 to 79±5 cm H2O in the two groups , respectively . There was no significant reduction in blood pressure during the study or at follow-up in either group . Fissure healing was complete in 9 patients ( 38 percent ) receiving oral diltiazem and 15 ( 65 percent ) on topical treatment by eight weeks . Oral diltiazem caused side effects in eight patients ( rash , two ; headaches , two ; nausea or vomiting , three ; reduced smell and taste , one ) , whereas no side effects were seen in those receiving topical therapy ( P=0.001 ) . CONCLUSION : Oral and topical diltiazem heal chronic anal fissures . Topical diltiazem is more effective , achieving healing rates comparable to those reported with topical nitrates , with significantly fewer side effects
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 .