The role of topical diltiazem in the treatment of chronic anal fissures that have failed glyceryl trinitrate therapy

Objective The treatment of anal fissures has evolved over the last 5 years with the development of topical treatments aimed at reducing sphincter hypertonia. This is thought to improve anal mucosal blood flow and promote healing of the fissure. This study reports the use of topical diltiazem in patients with chronic anal fissures that have failed previous treatment with topical 0.2% glyceryl trinitrate (GTN). Patients and methods Forty‐seven patients with chronic anal fissure who had previously failed at least one course of topical GTN were recruited prospectively from a single centre. Patients were instructed to apply 2 cm (approximately 0.7 g) of 2% diltiazem cream to the anal verge twice daily for eight weeks. Symptoms of pain, bleeding and itching were recorded on a linear analogue score prior to starting the cream and then repeated at 2 weekly intervals. Patients were asked to report side‐effects throughout the study period. Healing of the fissure was assessed after 8 weeks of treatment. Results Forty‐six patients completed treatment; of these, 22 had healed fissures (48%). Ten of the 24 patients with persistent fissures were symptomatically improved and wished no further treatment. Of the 14 patients who remained symptomatic, one was given a repeat course of 0.2% glyceryl trinitrate with subsequent healing of the fissure, 10 were recruited into an ongoing study involving injections of botulinum toxin into the internal anal sphincter and three were referred for surgery. Conclusion This study shows that topical 2% diltiazem is an effective and safe treatment for chronic anal fissure in patients who have failed topical 0.2% GTN. The need for sphincterotomy can be avoided in up to 70% of cases.     

Topical 0.2% glyceryl trinitrate ointment for anal fissures: long-term efficacy in routine clinical practice

Objective Randomized controlled trials have reported fissure healing rates of 60–70% using topical 0.2% GTN ointment, but the effectiveness of this therapy in routine clinical practice, particularly in the long term, is uncertain. This study aimed to evaluate the efficacy of topical GTN for anal fissures in an outpatient setting. Patients and methods A case note review and postal questionnaire survey were undertaken for patients with a diagnosis of anal fissure dispensed 0.2% GTN ointment from one hospital pharmacy over a two year period (June 1996–May 1998). Results Ninety‐three patients (53 male) applied 0.2% GTN ointment twice daily to the anoderm for anal fissure. They were reviewed on average 8 (2–16), weeks later, by which time 57 (61%) fissures had healed, 33 persisted and 3 patients were lost to follow up. Seventy‐two patients (41male), median age 42 (22–83) years, returned completed questionnaires (77% response rate). Forty‐nine (68%) had healed with GTN, but 25 had recurrent symptoms after a median of 6 (1–18) months. Sixteen of those patients reporting symptomatic recurrence were prescribed further GTN for a recurrent fissure: 14 (88%) healed, but 2 persisted, and had surgery. In the other nine patients symptoms resolved spontaneously. Thirty‐five (49%) experienced headaches, 3 (4%) discontinuing treatment as a result. The median follow up was 25 (13–36) months. Conclusion 0.2% GTN heals 60% of fissures in the outpatient setting but half the patients develop headaches. Up to one third of healed fissures may recur within 18 months but the majority respond to further GTN. Only 4% of patients initially healed with GTN later require sphincterotomy for recurrences.     

Audit of topical glyceryl trinitrate for treatment of fissure-in-ano

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.     

Randomised trial of topical 0.2% glyceryl trinitrate and lateral internal sphincterotomy for the treatment of patients with chronic anal fissure: long-term follow-up.

OBJECTIVE: To compare outcomes 24 months after treatment of chronic anal fissure with 0.2% glyceryl trinitrate ointment (GTN) or lateral internal sphincterotomy. DESIGN: Prospective, randomised trial. SETTING: One teaching, one private, and 3 district hospitals, U.K. SUBJECTS: Seventy patients were randomised into two groups of 35 each to use 0.2% GTN ointment or have a lateral internal sphincterotomy. MAIN OUTCOME MEASURES: Resolution of symptoms and healing of fissures assessed after 24 months. RESULTS: All those operated on were initially cured but one fissure recurred after 8 months. Nineteen of 35 fissures treated with GTN healed. The remaining 16 patients randomised to use GTN ointment whose fissures did not heal were then treated by sphincterotomy. Three patients whose fissures healed successfully with GTN developed recurrences within 6 months of completing treatment. The remaining 16 of 19 patients treated with GTN whose fissures healed were free of symptoms with no clinical evidence of recurrence after 24 months follow-up. CONCLUSIONS: Many anal fissures heal with topical treatment with GTN. Lateral internal sphincterotomy remains effective but should be reserved for patients who fail to respond to initial chemical sphincterotomy.     

Effect of topical glyceryl trinitrate on anodermal blood flow in patients with chronic anal fissures

Introduction : Recent studies have highlighted the role of increased internal anal sphincter pressure and decreased anodermal blood flow in the pathogenesis of chronic anal fissures. The duration of the effect of topical 0.2% glyceryl trinitrate (GTN) ointment on anodermal blood flow in fissure and normal areas was investigated in patients with chronic anal fissures. Methods : Six patients with chronic anal fissures in the posterior midline participated in the study. Blood flow measurements were performed on the anoderm using laser Doppler flowmetry before and immediately after the topical application of 0.2% GTN ointment and subsequent readings were taken at 5, 15, 30, 45 and 60 min in all four quadrants. Results : The mean anodermal blood flow in the fissure region is significantly lower than the mean blood flow of the rest of the anoderm before 0.2% GTN ointment is applied (228.7 ± 61.8 flux units vs 439.3 ± 25.5 flux units, respectively; P < 0.05). Immediately after the application of local 0.2% GTN ointment there is a significant increase in anodermal blood flow over the anal fissure region (457.8 ± 56.5 flux units; P < 0.05) compared to the rest of the anoderm (457.4 ± 30.8 flux units). This increase is most marked at 5 min post‐GTN ointment application in the fissure area (474.6 ± 41.1 flux units) and the blood flow in the fissure region is consistently above the rest of the anoderm for most of the 60 min. Conclusion : There is clearly reduced blood flow to the chronic anal fissure region compared to the rest of the anoderm. Topical application of glyceryl trinitrate ointment seems to significantly improve the blood flow to the fissured area in the first hour. This may therefore help in the healing of chronic anal fissures.     

A Comparison of the Effects of Diltiazem and Glyceryl Trinitrate Ointment in the Treatment of Chronic Anal Fissure: A Randomized Clinical Trial

Purpose Anal fissure is a common problem affecting all age groups with an equal incidence in both sexes. Traditional surgical treatments, like manual anal dilatation or a sphincterotomy, effectively heal most fissures within a few weeks but such procedures may result in anal incontinence. In recent years, various medical therapies have been used for the treatment of chronic anal fissure without fear of incontinence. Methods Ninety patients with a symptomatic anal fissure were randomly divided into three groups. Group I was treated with 2% diltiazem ointment, Group II was treated with 0.2% glyceryl trinitrate (GTN) ointment, and Group III was kept as the control group. The improvement in the signs and symptoms, the time taken for healing, and side effects were recorded in each group. The patients were followed up monthly and then every 3 months for any recurrence of fissure. Comparative evaluations of the three groups regarding an improvement in symptoms, progress in healing, appearance of side effects, and recurrence were made using the Tukey HSD test. Results Diltiazem ointment was found to be superior regarding pain relief, fewer side effects, and late recurrence as compared with GTN ointment. Conclusion Diltiazem ointment (2%) and GTN ointment (0.2%) are both effective treatment modalities for chronic anal fissure, with diltiazem giving better patient outcome.     

Treatment of anal fissure with glyceryl trinitrate in patients referred for surgical management

Background : A number of recent studies indicate that anal fissure may be treated by applying glyceryl trinitrate (GTN) ointment. The present study aims to determine the effectiveness and patient acceptability of GTN treatment for patients referred to a consultant surgeon. Methods : A prospective study of 65 consecutive patients referred to one surgeon (ALP) over a 12‐month period was undertaken. All patients were offered 0.2% GTN ointment to be applied intra‐anally four times daily for 4 weeks. Informed consent was obtained and review planned for 4 weeks. Results : Fourteen patients declined treatment and nine of the 14 (64%) subsequently underwent lateral sphincterotomy. Twelve of the 51 patients (18.5%) who accepted treatment could not complete it due to headache or persisting severe anal pain. Thirty‐nine of the 51 patients (77%) were able to complete 4 weeks of treatment. Twenty‐two of the 39 reported an improvement in symptoms. A total of 22 patients (43%) who started GTN treatment subsequently underwent lateral sphincterotomy. Conclusions : Evidence from the present study suggests that GTN ointment has a place in the management of referred patients with severe and/or chronic anal fissure, but sphincterotomy remains an important treatment option for the majority.     

A prospective randomized trial of diltiazem and glyceryltrinitrate ointment in the treatment of chronic anal fissure

Objective The aim of this study was to compare prospectively diltiazem with GTN ointment in the treatment of anal fissure. Patients and methods Of 43 outpatients with chronic anal fissure, 22 patients were randomized to topical diltiazem (2%) ointment and 21 patients to glyceryltrinitrate (GTN) (0.5%) ointment twice daily for 8 weeks. During the course of treatment each patient was seen three times. Side‐effects and healing were recorded. Results Healing occurred in 19 of 22 patients treated with diltiazem and 18 of 21 patients were cured with GTN (P = 0.95). Those who were treated with nitroglycerin ointment developed headache and dizzness developed after GTN in 33.3% of cases while no patient had any side‐effects after diltiazem. Conclusions Diltiazem and glyceryltrinitrate (GTN) were equally effective in healing anal fissure but the former resulted in fewer side‐effects.     

Recent advances in the pharmacotherapy of chronic anal fissure: an update

Surgical sphincterotomy reduces anal tone and sphincter spasm and promotes ulcer healing. Because the surgery is associated with the side effect of faecal incontinence, pharmacological agents to treat chronic anal fissure have been explored recently. Glyceryl trinitrate (GTN) ointment (0.2%) has an efficacy of up to 68% in healing chronic anal fissure, but it is associated with headache as the major and most common side effect. Though botulinum toxin injected into the anal sphincter healed over 80% of chronic anal fissures, it is more invasive and expensive than GTN therapy. Diltiazem ointment achieved healing of chronic anal fissure comparable to 0.2% GTN ointment but was associated with fewer side effects. Other drugs that have been tried are lidocaine, the alpha-adrenergic antagonist indoramin, and the potassium channel opener minoxidil.     

Comparative Study of Glyceryl Trinitrate Ointment Versus Surgical Management of Chronic Anal Fissure

Chronic Anal Fissure (CAF) is common perineal condition and well-known painful entity. Standard surgical treatment even though available, may require long hospital stay and sometimes have worrying complications like anal incontinence. So non-surgical treatment, Glyceryl Trinitrate has been shown to be an effective for chronic anal fissure. It decreases anal tone and ultimately heals the anal fissure. The present study is the attempt to know the efficacy of 0.2% Glyceryl Trinitrate ointment in the treatment of chronic anal fissure and to compare the effectiveness of 0.2% Glyceryl Trinitrate ointment (GTN) versus fissurectomy with lateral internal sphincterotomy (LIS) and fissurectomy with posterior internal sphincterotomy (PIS) in the management of chronic anal fissure. This is a prospective comparative study of management of chronic anal fissure done in our hospital during the period of one and half year from October 2005 to March 2007. Thirty patients treated with 0.2% Glyceryl Trinitrate ointment and 30 patients treated with fissurectomy and lateral internal sphincterotomy and 30 patients treated with posterior internal sphincterotomy, for chronic anal fissure were selected for study. A single brand of 0.2% Glyceryl Trinitrate ointment (Nitrogesic) used for trial arm. Dose of administration was 1.5 cm to 2 cm in the anal canal with device provided by manufacturers of the proprietary preparation and applied twice a daily for 12 weeks. Patients were followed up for 12 weeks and thereafter evaluated for relief of symptoms in all three groups. Observations were recorded at 2 weeks; 6 weeks and 12 weeks of follow up period, regarding symptoms like pain and bleeding during defecation, healing of CAF and also for side effects like headache in GTN group and flatus, fecal incontinence in surgical groups. Data collected in proforma and analyzed. Study revealed CAF was more in male 59 patients (66%) than the female 31 patients (34%), the ratio being 1: 0.52. The maximum number of patients was encountered in the age group of 20 to 40 years with mean duration of age 34.14 years. In all three groups symptoms like pain, bleeding, constipation and sphincter spasm were present. Sentinel pile was present in 56% of the patients. Common site of fissure was found to be posterior in 94% of patients. Observations with respect to relief of pain, no bleeding and healing were recorded at 2, 6 and 12 weeks of duration. Lateral sphincterotomy remains effective but should be reserved for the patients who fail to respond to initial chemical sphincterotomy or GTN therapy. GTN is good alternative mode of therapy for patients who refuse surgery and prefer medical line of treatment.     

Glyceryl trinitrate treatment of chronic fissure in ano: one year's experience with 0.5% GTN paste

OBJECTIVE: Assessment of the efficacy of topical 0.5% glyceryl trinitrate (GTN) paste in the treatment of chronic fissures in ano. PATIENTS AND METHODS: Forty-five patients were treated with 0.5% GTN paste and reviewed at 3, 6 and 12 weeks to assess symptoms, side effects and fissure healing. RESULTS: At 6 weeks, 73% of patients had no fissures. In 27% of cases treatment was unsuccessful. At three month follow up there was no early recurrence. The prevalence of headaches was 84% with 11% headache related non-compliance. CONCLUSIONS: The use of 0.5% GTN induces rapid healing of chronic anal fissures with a 73% healing rate in this study. Successful treatment may come at the expense of a high incidence of headaches and a lower compliance than found in studies involving a lower concentration of GTN. A balance is required between fissure healing and headache intolerance.     

FISSURE IN ANO

The present study documents a 15 year experience with anal dilatation in patients with fissure in ano. Patients who were unable to tolerate rectal examination were admitted urgently for anal dilatation. Patients in whom rectal examination and proctoscopy was possible were offered an anal dilator and were reviewed after 4 weeks. Patients who preferred not to use an anal dilator or who had not become asymptomatic were admitted for elective anal dilatation. Four finger anal dilatation was performed under general anaesthesia. Between 1975 and 1990 104 patients underwent 111 procedures. The male to female ratio was 1.3:1. Five patients were re-operated because of failure of resolution of symptoms. Three patients with anal fissures and Crohn's disease were successfully managed by anal dilatation. Nine patients had excision of a ‘sentinel pile’ in addition to anal dilatation. Ten patients were admitted acutely. One patient developed a perineal haematoma. Seventy-four procedures were performed as day cases. There was no mortality associated with the procedure. At the time of discharge from the clinic no patient complained of problems with continence. These results support our policy of gentle anal dilatation as first management choice in the treatment of anal fissure.     

Topical nitroglycerin versus lateral internal sphincterotomy for chronic anal fissure: prospective, randomized trial

Introduction: Topical nitroglycerin (GTN) is one of the medical treatments of choice in chronic anal fissure. The present prospective, randomized, clinical trial was conducted to study the symptomatic relief, healing, and changes in the maximum anal resting pressure (MARP) in patients with chronic anal fissure comparing topical GTN and lateral sphincterotomy. Methods: Forty consecutive patients with chronic anal fissure were randomized for treatment with either topical GTN or internal sphincterotomy (20 patients in each group). Anal manometry was done before treatment in all patients, and 1 h after application of GTN or sphincterotomy. Patients were followed at 2‐weekly intervals for 6 weeks for symptomatic relief and healing. Results: Both GTN and sphincterotomy brought about a highly significant, but comparable drop in the MARP after treatment (P < 0.0001 in both groups). Sphincterotomy relieved pain much earlier compared to GTN (70% vs 40% at 2 weeks, P = 0.0032); but after 4 weeks of treatment, pain relief in both groups was comparable. Healing in the sphincterotomy group was also earlier than with GTN (55% vs 0% at 2 weeks, P < 0.0001; and 85% vs 30% at 4 weeks, P < 0.0001); but after 6 weeks, healing in both groups was comparable. Sphincterotomy had a significant incidence of minor, short‐term complications; it also required surgical expertise, theatre time, and day‐care beds. Nitroglycerin is safe, with mild and tolerable side‐effects of headache and local burning sensation. Conclusion: Topical GTN should be the initial treatment in chronic anal fissure. Lateral sphincterotomy should be reserved for patients with severe disabling pain (because pain relief is much faster), and for patients not responding to at least 4 weeks of GTN therapy.     

A prospective, randomized, double-blind, placebo-controlled trial of glyceryl-trinitrate ointment in the treatment of children with anal fissure

BACKGROUND: Anal fissure in children usually is treated by sitz baths, stool softeners, and analgesic ointments. However, some cases are intractable to the treatment. In recent years, it has been reported that nitric oxide donors such as local glyceryl-trinitrate (GTN) ointment causes a reversible chemical sphincterotomy. Although the GTN ointment can be an alternative therapy for adult cases, it has not yet been studied in the children who suffer from anal fissure. METHODS: Sixty-five children with anal fissure were divided randomly into 3 groups. Each group received double-blinded a topical ointment that contained either 0.2% GTN, 10% lidocaine, or placebo. These ointments were applied to the lowest part of the anal canal twice daily. Patients were periodically reviewed, and the study was ended after 8 weeks. RESULTS: Complete healing of the fissure occurred in 26 of 31 (83.9%) patients treated with GTN, 7 of 14 (50%) patients treated with lidocaine, and 6 of 17 (35.2%) treated with placebo. In 29 of 31 (93.5%) GTN-treated patients, a total relief of symptoms was observed, whereas this occurred in 7 of 14 (50%) treated with lidocaine and 6 of 11 (35.3%) in the placebo group. The differences between the study group and control groups were highly statistically significant (P < .001). CONCLUSION: The majority of children suffering from anal fissure will be cured and have relief of symptoms after topical application of GTN ointment to the anal canal.     

Comparison of topical glyceryl trinitrate ointment and oral nifedipine in the treatment of chronic anal fissure

This study was designed to compare the effect of topical glyceryl trinitrate (GTN) and oral nifedipine treatments on maximal anal resting pressure (MARP) and subsequently to assess their effectiveness in healing of chronic anal fissure (CAF). Patients were allocated randomly to receive either oral nifedipine retard (10 patients) 20 mg twice daily or instructed to apply glyceryl trinitrate (0.2 percent) ointment (10 patients) into the lower half of the anal canal twice daily. They were reviewed and assessed at the first visit and every fortnight for measurement of MARP, pain scores, blood pressure, pulse rate, healing of the fissure and adverse effects. Treatment were continued until healing had occurred or for up to 8 weeks. MARP values before and after application of the GTN ointment was 113.2 cm H2O and 72.5 cm H2O respectively (P < 0.001). Nifedipine caused a reduction in mean MARP from 105.2 to 74.0 cm H2O (P < 0.001). Linear analogue pain scores were significantly reduced after 2 weeks treatment with GTN and nifedipine (P < 0.001) and continued throughout the treatment period. At the end of the study; 7 of the 10 patients in the GTN group were deemed to be healed (5) or improved (2), compared with 6 of the 10 patients in the nifedipine group (5 healed, 1 improved). Headaches occurred in 3 patients in the GTN group, compared with one patient in the nifedipine group. There was no significant difference between GTN and nifedipine in terms of reduction in MARP and pain score, healing of the fissure and incidence of early recurrence and side effects of treatments. We conclude that GTN ointment and oral nifedipine are equally effective in the treatment of chronic anal fissure.     

Treatment of resistant anal fissure with advancement anoplasty

Objective The primary aim of this study was to assess the outcome of advancement anoplasty in the treatment of chronic anal fissure, resistant to conventional therapy. The secondary aim was to evaluate the anal resting pressure in these patients with resistant fissures. Patients and methods Over a five‐year period eight patients (2 male, median age 55 years, range 20–74) with resistant anal fissure were referred from 6 centres. They had endured symptoms for a median of 8 years (range 2–20) and had undergone a median of 2 previous surgical procedures (range 1–3), including lateral sphincterotomy and anal dilatation. Anorectal physiological testing was performed on all patients who then underwent advancement anoplasty. The outcome was analysed retrospectively. Results Pre‐operative anorectal physiological testing showed a significantly lowered median maximal anal resting pressure of 42 mm H₂O (range 12–72 mm H₂O, normal range > 60 mm), P = 0.03. All patients underwent advancement anoplasty. At a median of seven months follow‐up (range 2–22) seven of eight patients had healed their fissure and were asymptomatic. The median healing time was four months (range 2–6). Conclusion Patients with chronic anal fissure, resistant to conventional therapy, may be successfully treated by advancement anoplasty. Healing time however, may be prolonged. In this series patients had a decreased anal resting pressure rather than anal hypertonia.     

Randomized clinical trial assessing the side-effects of glyceryl trinitrate and diltiazem hydrochloride in the treatment of chronic anal fissure

INTRODUCTION: Glyceryl trinitrate (GTN) ointment (0 small middle dot2 per cent) has an efficacy of up to 68 per cent in healing chronic anal fissure, but with headache as a major side-effect. Diltiazem hydrochloride (DTZ) cream (2 per cent) is expected to have fewer side-effects. METHODS: A prospective double-blind randomized two-centre trial requiring at least 26 patients in each group (alpha = 0.05, beta = 0.9) was instituted after approval of the local ethics committee, to compare the incidence of side-effects (primary endpoint) with 0.2 per cent GTN ointment and 2 per cent DTZ cream in the treatment of chronic anal fissure. Treatments were applied perianally, twice daily for 6-8 weeks. All patients gave written informed consent. RESULTS: Both groups were comparable in patient demographics and clinical characteristics. Twelve patients violated the protocol, withdrew or did not attend follow-up. There were more side-effects with GTN (21 of 29 patients) than with DTZ (13 of 31) (relative risk (RR) 1.84 (95 per cent confidence interval (c.i.) 1.11 to 3.04), P = 0.01). In particular, more headaches occurred with GTN (17 of 29 patients) than with DTZ (eight of 31) (RR 2.06 (95 per cent c.i. 1.18 to 3.59), P = 0.01). There were no significant differences in healing and symptomatic improvement rates between patients receiving GTN (25 of 29) and DTZ (24 of 31). DISCUSSION: DTZ cream caused substantially fewer headaches than GTN ointment. There was no significant difference in the healing or improvement of chronic anal fissure between the treatments. DTZ may be the preferred first-line treatment for chronic anal fissure.     

Changing patterns of treatment for chronic anal fissure.

To assess changing patterns of treatment for chronic anal fissure, a retrospective analysis of treatment for chronic anal fissure within one hospital between January 1990 and December 1996 was undertaken. A total of 221 patients received treatment for a chronic anal fissure in this period, of whom 209 had a surgical procedure. Manual dilatation of the anus was performed in 21 patients (10%) and has not been performed since 1995. Lateral internal sphincterotomy was performed in 183 patients (88%) and continues to be the mainstay of treatment. Five female patients (2%) were identified as having a sphincter defect by anal manometry combined with endoanal ultrasound and were treated by an anal advancement flap. From 1996 onwards, 15 patients (7%) were treated by topical glyceryl trinitrate (GTN) paste as the first line of treatment. Of these patients, nine have experienced healing of their fissure, and three have had relief of pain without healing of the fissure. Three have gone on to have a lateral internal sphincterotomy. Lateral internal sphincterotomy remains the primary form of treatment for chronic anal fissure. GTN cream has increasingly been offered as preliminary treatment over the last 12 months. Perioperative use of endoanal ultrasound allowed identification of patients who may be at high risk of postoperative incontinence from a sphincterotomy. An anal advancement flap has been used as an alternative surgical approach for these patients.     

Modern perspectives in the treatment of chronic anal fissures

INTRODUCTION

Anal fissures are commonly encountered in routine colorectal practice. Developments in the pharmacological understanding of the internal anal sphincter have resulted in more conservative approaches towards treatment. Simple measures are often effective for early fissures. Glyceryl trinitrate is well established as a first-line pharmacological therapy. The roles of diltiazem and botulinum, particularly as rescue therapy, are not well understood. Surgery has a defined role and should not be discounted completely.

METHODS

Data were obtained from Medline publications citing ‘anal fissure’. Manual cross-referencing of salient articles was conducted. We have sought to highlight various controversies in the management of anal fissures.

FINDINGS

Acute fissures may heal spontaneously, although simple conservative measures are sufficient. Idiopathic chronic anal fissures need careful evaluation to decide what therapy is suitable. Pharmacological agents such as glyceryl trinitrate (GTN), diltiazem and botulinum toxin have been subjected to most scrutiny. Though practices in the UK vary, GTN or diltiazem would be suitable as first-line therapy with botulinum toxin used as rescue treatment. Sphincterotomy is indicated for unhealed fissures; fissurectomy has been revisited and advancement flaps have a role in patients in whom sphincter division is not suitable.     

Evaluation of the efficacy of a new graduated anal dilator in the treatment of acute anal fissures

Dilatation of the anal sphincter with anal dilators for the treatment of acute anal fissure is efficacious, economic and safe but not always correctly executed with a negative repercussions on the technical results. Our study was aimed at comparing the efficacy of new graduated dilator with a progressively graduated diameter, using a standard treatment schedule, or a free schedule in comparison with the use of multiple classic dilators currently available for the resolution of anal fissures. A series of 60 patients, 35 female and 25 male, with a clinical diagnosis of acute anal fissure in the absence of a hypotonic anal sphincter, abscess or perianal fistula, hemorrhoidal thrombosis, chronic inflammatory bowel diseases or lower gastrointestinal neoplasms were preliminarily evaluated with the solid sphere test and randomly divided into three groups: the first was treated with the new graduated dilator with a standard treatment schedule (20 patients); the second was treated with multiple anal dilators (20, 23, 27 mm) (20 patients) using a standard treatment schedule, and the third group (20 patients) was treated with the new graduated dilator according to a free treatment schedule. After four weeks of treatment, 91% of all patients showed resolution of the anal fissure. Patients treated with new graduated dilator and those treated with multiple dilators according to the standard schedule showed similar 90% rates of fissure healing in comparison to the 92% treated with the graduated dilator according to the free schedule. The tolerability and manageability of the new single graduated dilator was judged positively by all patients in the treated groups. The use of the graduated anal dilator according to a free treatment schedule seems to induce lasting resolution of acute anal fissures with similar results to those achieved using traditional multiple dilators, while proving better tolerated by the patients.