Randomised controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate.
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BACKGROUND: Topical application of glyceryl trinitrate (GTN) ointment heals chronic anal fissures, providing an alternative to the traditional first line treatment of surgical sphincterotomy. AIMS: To determine the most effective dose of topical GTN for treatment of chronic anal fissures and to assess long term results. METHODS: Seventy consecutive patients with chronic anal fissure, were randomly allocated to eight weeks treatment with placebo, 0.2% GTN three times daily, or GTN starting at 0.2% with weekly 0.1% increments to a maximum of 0.6%, in a double blind study. RESULTS: After eight weeks fissure had healed in 67% of patients treated with GTN compared with 32% with placebo (p=0.008). No significant difference was seen between the two active treatments. Headaches were reported by 72% of patients on GTN compared with 27% on placebo (p<0.001). Maximum anal sphincter pressure reduced significantly from baseline by GTN treatment (p=0.02), but not placebo (p=0.8). Mean pain scores were lower after treatment with GTN compared with placebo (NS). Of fissures healed with placebo 43% recurred, compared with 33% of those healed with 0.2% GTN and 25% healed with escalating dose GTN (p=0.7). CONCLUSIONS: GTN is a good first line treatment for two thirds of patients with anal fissure. An escalating dose of GTN does not result in earlier healing. Significant recurrence of symptomatic fissures and a high incidence of headaches are limitations of the treatment. (+info)
A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure.
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BACKGROUND AND METHODS: Lateral internal sphincterotomy, the most common treatment for chronic anal fissure, may cause permanent injury to the anal sphincter, which can lead to fecal incontinence. We compared two nonsurgical treatments that avert the risk of fecal incontinence. We randomly assigned 50 adults with symptomatic chronic posterior anal fissures to receive treatment with either a total of 20 U of botulinum toxin injected into the internal anal sphincter on each side of the anterior midline or 0.2 percent nitroglycerin ointment applied twice daily for six weeks. RESULTS: After two months, the fissures were healed in 24 of the 25 patients (96 percent) in the botulinum-toxin group and in 15 of the 25 (60 percent) in the nitroglycerin group (P=0.005). No patient in either group had fecal incontinence. At some time during treatment, five patients in the nitroglycerin group had transient, moderate-to-severe headaches that were related to treatment. None of the patients in the botulinum-toxin group reported adverse effects. Ten patients who did not have a response to the assigned treatment - 1 in the botulinum-toxin group and 9 in the nitroglycerin group - crossed over to the other treatment; the fissures subsequently healed in all 10 patients. There were no relapses during an average of about 15 months of follow-up. CONCLUSIONS: Although treatment with either topical nitroglycerin or botulinum toxin is effective as an alternative to surgery for patients with chronic anal fissure, botulinum toxin is the more effective nonsurgical treatment. (+info)
Lateral internal sphincterotomy is not redundant in the era of glyceryl trinitrate therapy for chronic anal fissure.
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Lateral internal sphincterotomy has been the standard treatment for chronic anal fissure, but fissure healing rates of up to 80% with topical glyceryl trinitrate (GTN) treatment have suggested that this operation may become redundant. We evaluated the results of topical treatment of chronic anal fissures with 0.2% GTN for 6 weeks in the outpatient clinical setting, outside the confines of a randomized clinical trial. The role of lateral internal sphincterotomy in the GTN era was also assessed. GTN induced fissure healing in 21 of 49 consecutive patients. Fissures healed spontaneously in 2 patients who discontinued GTN because of headache. Lateral internal sphincterotomy was performed in 26 patients who had persistent symptoms after 6 weeks of GTN therapy. At the 6-week post-sphincterotomy review, all fissures had healed and there were no complications. In this study topical GTN for treatment of chronic anal fissure in the outpatient setting was not as effective as demonstrated in controlled clinical trials. Lateral internal sphincterotomy is still a good therapeutic option, especially in patients not responding to GTN. (+info)
Audit of topical glyceryl trinitrate for treatment of fissure-in-ano.
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PURPOSE: To clarify the clinical role of topical glyceryl trinitrate (GTN) in the management of anal fissures. PATIENTS AND METHODS: Fifty-six consecutive patients with fissure-in-ano attending a colorectal clinic from April 1997 to May 1998 included 16 acute and 40 chronic anal fissures. Patients were instructed to apply 0.2% 0.5 g of GTN to the painful area of the anus. Patients were followed-up in the clinic at 4, 8 and 12 weeks, and by telephone interviews at a median follow up of 10 months. RESULTS: Ten of 16 acute fissures (63%) were healed by 4 weeks and 13 (81%) by 8 weeks. Thirteen of 40 chronic fissures (33%) were healed by 8 weeks and 20 (50%) by 12 weeks. Seventeen patients (30%) underwent lateral sphincterotomy and all healed. There were five recurrences within 3 months of treatment with GTN. Thirty-four (61%) suffered from headaches, eight being severe headaches. None of the patients developed incontinence with GTN or lateral sphincterotomy. CONCLUSIONS: Treatment of fissure-in-ano using GTN ointment was effective in up to 50% of patients with chronic anal fissure, and has the benefit of being repeatable if the fissure recurs. Patients should be aware that treatment is likely to take some months to be effective and is associated with significant side effects in up to 15% of patients. (+info)
Neuromyogenic properties of the internal anal sphincter: therapeutic rationale for anal fissures.
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Lateral sphincterotomy diminishes internal anal sphincter hypertonia and thereby reduces anal canal pressure. This improves anal mucosal blood flow and promotes the healing of anal fissures. However, sphincterotomy can be associated with long term disturbances of sphincter function. The optimal treatment for an anal fissure is to induce a temporary reduction of anal canal resting pressure to allow healing of the fissure without permanently disrupting normal sphincter function. Broader understanding of the intrinsic mechanisms controlling smooth muscle contraction has allowed pharmacological manipulation of anal sphincter tone. We performed an initial Medline literature search to identify all articles concerning "internal anal sphincter" and "anal fissures". This review is based on these articles and on additional publications obtained by manual cross referencing. Internal anal smooth muscle relaxation can be inhibited by stimulation of non-adrenergic non-cholinergic enteric neurones, parasympathetic muscarinic receptors, or sympathetic beta adrenoceptors, and by inhibition of calcium entry into the cell. Sphincter contraction depends on an increase in cytoplasmic calcium and is enhanced by sympathetic adrenergic stimulation. Currently, the most commonly used pharmacological agent in the treatment of anal fissures is topical glyceryl trinitrate, a nitric oxide donor. Alternative agents that exhibit a similar effect via membrane Ca2+ channels, muscarinic receptors, and alpha or beta adrenoceptors are also likely to have a therapeutic potential in treating anal fissures. (+info)
Fissurectomy as a treatment for anal fissures in children.
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INTRODUCTION: Anal fissures, characterised by painful defecation and rectal bleeding, are common in both children and infants. A significant proportion are resistant to simple laxative therapy, and no simple surgical treatment has been described which does not risk compromising sphincteric function. This study reports the initial experience of fissurectomy as a treatment of this condition. PATIENTS AND METHODS: Over a 36 month period, 37 children with an anal fissure were treated by fissurectomy. There were 14 boys and 23 girls, with an age range of 17 weeks to 12 years. Fissurectomy was performed under general anaesthetic, with additional caudal anaesthesia. Stay sutures were used to avoid the need for an anal retractor, thereby preventing stretching of the internal anal sphincter. Of the 37 operations, 36 (97%) were performed as day cases and all children were discharged on laxative therapy. RESULTS: At review, 6 weeks postoperatively, 30 (81%) were asymptomatic. Six (16%) patients were symptomatic; however, 4 of these had failed to comply with the postoperative laxative regimen. One patient failed follow-up. CONCLUSIONS: Fissurectomy is a successful treatment for anal fissures, when combined with postoperative laxative therapy. As dilatation of the internal anal sphincter is not involved, the risk of iatrogenic faecal incontinence is obviated. (+info)
Topical nitrates potentiate the effect of botulinum toxin in the treatment of patients with refractory anal fissure.
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BACKGROUND: Anal fissure is perpetuated by high sphincter pressures and secondary local ischaemia. Pharmacological approaches include topical nitrates and botulinum toxin (BT) which act to reduce anal pressure. BT lowers anal pressure by preventing acetylcholine release from nerve terminals while topical nitrates act by donating nitric oxide (NO). The aims of the present study were to compare the therapeutic effect and lowering action on internal anal sphincter pressure of BT injection and local application of isosorbide dinitrate (ID) compared with BT given alone, in patients with chronic anal fissure (CAF) refractory to treatment with ID. METHODS: Thirty consecutive patients with CAF who did not respond to previous topical ID treatments were randomly assigned to receive one of the following treatments: group A, injection of BT (20 U into the internal anal sphincter) and subsequent daily applications of ID (2.5 mg three times daily for three months); and group B, BT injection only (20 U). If at the end of six weeks following BT injection no improvement was seen in group B, ID was added. A series of anal pressure measurements, including resting basal pressure and resting pressure following topical ID (1.25, 2.5, and 3.75 mg), was carried out both before and two weeks after 20 U of BT injection into the internal anal sphincter. At the end of the trial, patients were followed up for an average period of 10 months. FINDINGS: At six weeks the fissure healing rate was significantly higher in group A patients (10/15 (66%)) compared with group B (3/15 (20%)) (p=0.025). At eight and 12 weeks, no significant differences were seen: 11/15 (73%) v 11/15 (73%) and 9/15 (60%) v 10/15 (66%), group A v group B, respectively. Maximum anal resting pressure (MARP) was significantly lower two weeks after BT injection than baseline MARP (90 (4) v 110 (5) mm Hg; p<0.001). A significantly greater reduction in MARP following local application of ID was achieved after BT injection compared with that achieved before BT injection (p=0.037) INTERPRETATION: (1) Combined BT injection and local application of ID in patients with CAF who failed previous treatment with ID was more effective than BT alone. This treatment modality appears to be safe and promising. (2) ID application induced a greater reduction in MARP following BT injection compared with ID application before BT injection. The improved potency of ID on MARP after BT injection suggests a primary cholinergic tonus dominance in some patients and not, as previously claimed, anal sphincter insensitivity to nitrates. (+info)
Common anorectal conditions: Part II. Lesions.
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Patients with a wide variety of anorectal lesions present to family physicians. Most can be successfully managed in the office setting. A high index of suspicion for cancer should be maintained and all patients should be questioned about relevant family history or other indications for cancer screening. Patients with condylomata acuminata must be examined for human papillomavirus infection elsewhere after treatment of the presenting lesions. Their sexual partners should also be counseled and screened. Both surgical and nonsurgical treatments are available for the pain of anal fissure. Infection in the anorectal area may present as different types of abscesses, cryptitis, fistulae or perineal sepsis. Fistulae may result from localized infection or indicate inflammatory bowel disease. Protrusion of tissue through the anus may be due to hemorrhoids, mucosal prolapse, polyps or other lesions. (+info)