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 dose finding study with 0.1%, 0.2%, and 0.4% glyceryl trinitrate ointment in patients with chronic anal fissures
Background : Anal fissure is a common painful condition affecting the anal canal . The majority of acute fissures heal spontaneously . However , some of these acute fissures do not resolve but become chronic . Chronic anal fissures were traditionally treated by anal dilation or by lateral sphincterotomy . However , both of these surgical treatments may cause a degree of incontinence in up to 30 % of patients . Several recent trials have shown that nitric oxide donors such as glyceryl trinitrate ( GTN ) can reduce sphincter pressure and heal up to 70 % of chronic fissures . Aim : This study addressed the dose-response to three different concentrations of GTN ointment compared with placebo in a double blind r and omised controlled trial . Method : A double blind , multicentre , r and omised controlled trial was set up to compare placebo ointment against three active treatment arms ( 0.1 % , 0.2 % , and 0.4 % GTN ointment applied at a dose of 220 mg twice daily ) in chronic anal fissures . The primary end point was complete healing of the fissure . Results : Two hundred patients were recruited over an eight month period from 18 centres . After eight weeks of treatment the healing rate in the placebo group was 37.5 % compared with 46.9 % for 0.1 % , 40.4 % for 0.2 % , and 54.1 % for 0.4 % GTN . None was significantly better than the placebo response . A secondary analysis excluded fissures without secondary criteria for chronicity . Healing rates were then found to be 24 % in the placebo group compared with 50 % in the 0.1 % GTN group , 36 % in the 0.2 % group , and 57 % in the 0.4 % GTN group . These values were statistically significantly different for the placebo group compared with 0.1 % GTN , 0.4 % GTN , and for the GTN treated group as a whole . Conclusions : The results of this study have demonstrated the significant benefit of topical GTN when applied to patients suffering from chronic anal fissures but acute fissures showed a tendency to resolve spontaneously . The high proportion of fissures which healed in the placebo group suggests that the definition of “ chronicity ” needs to be reassessed . Further studies are required to confirm the optimal therapeutic strategy
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 .