title: Local nitroglycerin for treatment of anal fissures: an alternative to lateral sphincterotomy?
abstract: OBJECTIVE
  Nitric oxide is an important neurotransmitter mediating internal anal sphincter relaxation. Patients suffering from fissure-in-ano were treated with topical nitroglycerine. The clinical evidence for therapeutic adequacy was examined in a prospective, randomized study.
  
  
  METHODS
  The study included 35 patients with acute and chronic anal fissures. 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 patients (10 acute and 5 chronic fissures), received topical anesthetic gel during therapy. Manometry was performed before and on days 14 and 28 in the course of topical application of either 0.2 percent glyceryl trinitrate ointment or anesthetic gel (lignocaine). Anal pressures were documented by recording the maximum resting and squeeze pressures.
  
  
  RESULTS
  In 60 percent of cases treated with topical nitroglycerine (Group A, 11 acute (91.6 percent) and 1 chronic (12.5 percent)), anal fissure healed within 14 days, in contrast to Group B in which no healing was 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 significantly superior to Group B (healing rate, 40 percent: 5 acute (50 percent); 1 chronic (20 percent)).
  
  
  CONCLUSIONS
  Previously increased maximum resting 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 H2O (11 percent)). However, anal pressures did not decrease significantly in the four chronic fissure patients from Group A, whose fissures only healed after 28 days. Similarly to these Group A chronic fissure patients, no significant anal pressure reduction was observed in any Group B patients. Except for mild headache (20 percent), no side effects of treatment were reported.
  
  
  CONCLUSIONS
  Topical application of nitroglycerine represents a new, easily handled, and effective alternative in the treatment of anal fissures. All of our patients reported a dramatic reduction in acute anal pain. However, it should be noted that a lack of sphincter tone reduction is a likely reason for the great tendency of chronic anal fissures to recur.
authors.affiliation: Department of Surgery, Karl-Franzens-University, Graz, Austria.
authors.forename: H
authors.initials: H
authors.lastname: Bacher
authors.forename: H J
authors.initials: HJ
authors.lastname: Mischinger
authors.forename: G
authors.initials: G
authors.lastname: Werkgartner
authors.forename: H
authors.initials: H
authors.lastname: Cerwenka
authors.forename: A
authors.initials: A
authors.lastname: El-Shabrawi
authors.forename: J
authors.initials: J
authors.lastname: Pfeifer
authors.forename: W
authors.initials: W
authors.lastname: Schweiger
mesh_terms: D000208:Acute Disease; D000285:Administration, Rectal; D000287:Administration, Topical; D000328:Adult; D001003:Anal Canal / Q000187:drug effects / Q000502:physiology / Q000601:surgery*; D000779:Anesthetics, Local / Q000008:administration & dosage / Q000627:therapeutic use; D002908:Chronic Disease; D005260:Female; D005401:Fissure in Ano / Q000188:drug therapy* / Q000503:physiopathology / Q000601:surgery; D005500:Follow-Up Studies; D005782:Gels; D006261:Headache / Q000139:chemically induced; D006801:Humans; D008012:Lidocaine / Q000008:administration & dosage / Q000627:therapeutic use; D008297:Male; D008365:Manometry; D008875:Middle Aged; D009119:Muscle Contraction / Q000502:physiology; D009126:Muscle Relaxation / Q000187:drug effects; D018377:Neurotransmitter Agents / Q000502:physiology; D009569:Nitric Oxide / Q000502:physiology; D005996:Nitroglycerin / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D011312:Pressure; D011446:Prospective Studies; D014665:Vasodilator Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D014945:Wound Healing
chemical_list: D000779:Anesthetics, Local; D005782:Gels; D018377:Neurotransmitter Agents; D014665:Vasodilator Agents; D009569:Nitric Oxide; D008012:Lidocaine; D005996:Nitroglycerin