LOCAL NITROGLYCERIN FOR TREATMENT OF ANAL FISSURES - AN ALTERNATIVE TO LATERAL SPHINCTEROTOMY

PURPOSE: Nitric oxide is an important neurotransmitter mediating inter nal anal sphincter relaxation. Patients suffering from fissure-ln-ano were treated with topical nitroglycerine. The clinical evidence for th erapeutic adequacy was examined in a prospective, randomized study. ME THODS: The study included 35 patients with acute and chronic anal fiss ures. In Group A, including 20 patients with the clinical diagnosis of acute (12 patients) and chronic (8 patients) anal fissures, treatment consisted of topical nitroglycerine. Group B, consisting of 15 patien ts (10 acute and 5 chronic fissures), received topical anesthetic gel during therapy. Manometry was performed before and on days 14 and 28 i n the course of topical application of either 0.2 percent glyceryl tri nitrate ointment or anesthetic gel (lignocaine). Anal pressures were d ocumented by recording the maximum resting and squeeze pressures. RESU LTS: In 60 percent of cases treated with topical nitroglycerine (Group A, 11 acute (91.6 percent) and 1 chronic (12.5 percent)), anal fissur e healed within 14 days, in contrast to Group B in which no healing wa s observed. The healing rate after one month was 80 percent (11 acute (91.6 percent) 5 chronic (62.5 percent)) in Group A and was significan tly superior to Group B (healing rate, 40 percent: 5 acute (50 percent ); 1 chronic (20 percent)). DISCUSSION: Previously increased maximum r esting pressures decreased from a mean value of 110 to 87 cm H2O. This represents a mean reduction of 20 percent (P = 0.0022). We also noted a significant decrease in squeeze pressures (from 177.8 to 157.9 cm H 2O (11 percent)). However, anal pressures did not decrease significant ly in the four chronic fissure patients from Group A, whose fissures o nly healed after 28 days. Similarly to these Group A chronic fissure p atients: no significant anal pressure reduction was observed in any Gr oup B patients, Except for mild headache (20 percent), no side effects of treatment were reported. CONCLUSIONS: Topical application of nitro glycerine represents a new, easily handled, and effective alternative in the treatment of anal fissures. Ail of our patients reported a dram atic reduction in acute anal pain. However, it should be noted that a lack of sphincter tone reduction is a likely reason for the great tend ency of chronic anal fissures to recur.