GLYCERYL TRINITRATE IS AN EFFECTIVE TREATMENT FOR ANAL-FISSURE

PURPOSE: It has been suggested that chronic anal fissure is ischemic i n origin because of poor blood supply and spasm of the internal anal s phincter. Nitric oxide donors such as glyceryl trinitrate (GTN) cause a chemical sphincterotomy leading to healing of the assure. This study addresses the hypothesis that topical GTN ointment may be an effectiv e nonsurgical treatment for chronic anal fissure. METHODS: Thirty-nine consecutive patients (23 women; median age, 54 (range, 16-54) years) with chronic anal fissure presenting to the surgical outpatient depart ment were treated for four to six weeks with 0.2 percent GTN ointment applied twice daily to the anoderm. Maximum anal resting pressure was measured at steady state before and after application of the ointment at the first visit. Patients were assessed at two weekly intervals. RE SULTS: Previous surgery for fissure had been performed in seven patien ts. There were 30 posterior and 9 anterior fissures. Resting maximum a nal resting pres sure fell from 122.1 +/- 44 to 72.5 +/- 33.3 cm of wa ter (mean +/- standard deviation) by 20 minutes after application of o intment (P < 0.0001; paired t-test). Healing was complete in 14 patien ts at four weeks and in 33 patients at six weeks. Fissures recurred in five patients after treatment had been stopped. Four recurrences were successfully treated by further GTN ointment and one by sphincterotom y. CONCLUSIONS: This study shows that most anal fissures can be treate d nonsurgically with topically applied 0.2 percent GTN ointment. Prosp ective, randomized controlled trials are now needed, because nonsurgic al treatment of anal fissure avoids permanent division of part of the sphincter and the consequent disturbance of continence mechanisms.