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 vs. lateral sphincterotomy for chronic anal fissure: Prospective, randomized trial
INTRODUCTION : Glyceryl trinitrate has been shown to be an effective treatment for  chronic anal fissure .  It decreases anal tone and ultimately heals anal fissures . The aim of this trial was to compare glyceryl trinitrate with lateral sphincterotomy ( current st and ard treatment ) as definitive management for  chronic anal fissure . METHODS : All patients with symptoms of chronic anal fissure were r and omly assigned to one of two treatment arms . The glyceryl trinitrate group applied 0.2 percent paste to the perianal area three times a day for eight weeks . Patients in the lateral sphincterotomy group underwent surgery on the next available operating list . Patients were review ed at two weekly intervals until the fissure healed . RESULTS : Sixty‐five patients were enrolled in the trial , with 31 in the lateral sphincterotomy group and 34 in the glyceryl trinitrate group . Five patients were excluded after r and omization . Twenty of 33 ( 60.6 percent ) glyceryl trinitrate patients had healed fissures in eight weeks compared with 26 of 27 ( 97 percent ) in the sphincterotomy group ( P = 0.001 ) . Twelve patients in the glyceryl trinitrate group had little improvement in their symptoms and underwent lateral sphincterotomy .  Poor tolerance and poor compliance with treatment were important factors in patients whose fissures did not heal with glyceryl trinitrate .  Fissures healed significantly faster after sphincterotomy compared with glyceryl trinitrate treatment ( P = 0.0001 ) . Nine of the 20 patients whose fissures healed with glyceryl trinitrate paste subsequently had a recurrence of their fissures . There were no long‐term complications from lateral sphincterotomy . CONCLUSION : Glyceryl trinitrate paste heals the majority of chronic anal fissures . However , a significant minority have little improvement or develop side effects and require conventional surgical treatment . Poor compliance with prescribed treatment often contributes to nonhealing . In addition , some fissures which initially heal with glyceryl trinitrate paste recur and require further treatment . Glyceryl trinitrate treatment is labor intensive for patients and physicians and has not been shown to be superior to lateral sphincterotomy
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 .