Glyceryl trinitrate vs. lateral sphincterotomy for chronic anal fissure - Prospective, randomized trial

INTRODUCTION: Glyceryl trinitrate has been shown to be an effective treatme nt for chronic anal fissure. It decreases anal tone and ultimately heals an al fissures. The aim of this trial was to compare glyceryl trinitrate with lateral sphincterotomy (current standard treatment) as definitive managemen t for chronic anal fissure. METHODS: All patients with symptoms of chronic anal fissure were randomly assigned to one of two treatment arms. The glyce ryl trinitrate group applied 0.2 percent paste to the perianal area three t imes a day for eight weeks. Patients in the lateral sphincterotomy group un derwent surgery on the next available operating list. Patients were reviewe d at two weekly intervals until the assure healed. RESULTS: Sixty-five pati ents were enrolled in the trial, with 31 in the lateral sphincterotomy grou p and 34 in the glyceryl trinitrate group. Five patients were excluded afte r randomization. Twenty of 33 (60.6 percent) glyceryl trinitrate patients h ad healed fissures in eight weeks compared with 26 of 27 (97 percent) in th e sphincterotomy group (P = 0.001). Twelve patients in the glyceryl trinitr ate group had little improvement in their symptoms and underwent lateral sp hincterotomy. Poor tolerance and poor compliance with treatment were import ant factors in patients whose assures did not heal with glyceryl trinitrate . Fissures healed significantly faster after sphincterotomy compared with g lyceryl trinitrate treatment (P = 0.0001). Nine of the 20 patients whose fi ssures healed with glyceryl trinitrate paste subsequently had a recurrence of their fissures. There were no long-term complications from lateral sphin cterotomy. CONCLUSION: Glyceryl trinitrate paste heals the majority of chro nic anal fissures. However, a significant minority have little improvement or develop side effects and require conventional surgical treatment. Poor c ompliance with prescribed treatment often contributes to nonhealing. In add ition, some fissures which initially heal with glyceryl trinitrate paste re cur and require further treatment. Glyceryl trinitrate treatment is labor i ntensive for patients and physicians and has not been shown to be superior to lateral sphincterotomy.