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 .
Nifedipine for local use in conservative treatment of anal fissures
PURPOSE : This study was performed according to a prospect i ve , r and omized , double-blind , multicenter design . The aim was to test the efficacy of local application of nifedipine gela in healing acute anal fissure  by relaxing the internal anal sphincter . METHODS : Two hundred eighty-three patients who gave informed consent were recruited ; they received a clinical examination . A question naire to evaluate the symptoms and the pain was administered , and a proctoscopy and anorectal manometry were performed . Patients treated with nifedipine ( n=141 ) used topical 0.2 percent nifedipine gel every 12 hours for three weeks . The control group , consisting of 142 patients , received topical 1 percent lidocaine and 1 percent hydrocortisone acetate gel during therapy . Manometry was performed before and on Days 14 and 21 . Anal pressures were measured by recording resting and squeeze pressures . RESULTS : Results obtained were as follows : total remission from acute anal fissure was achieved after 21 days of therapy in 95 percent of the nifedipine-treated patients ( P<0.01 ) , as opposed to 50 percent of the controls ( P<0.01 ) , and previously elevated maximum resting anal pressures decreased from a mean value ± st and ard deviation of 72.5±10.07 mmHg to 50.5±10.03 mmHg in the nifedipine group . This represents a mean reduction of 30 percent ( P<0.01 ) . We also observed a significant decrease in squeeze pressures in nifedipine-treated patients ( from a mean ± st and ard deviation of 130.5±19.25 mmHg to 108.5±18.55 mmHg , a mean reduction of 16.8 percent;P<0.01 ) . No changes in anal pressures were observed in the control group . We did not observe any systemic side effect or significant anorectal bleeding in patients treated with nifedipine . CONCLUSIONS : Our study clearly demonstrates that the therapeutic use of nifedipine , which at present is used only in cardiovascular pathologies , should be extended with local use to the conservative treatment of anal fissures
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 .