title: Concepts in pathogenesis and treatment of chronic anal fissure--a review of the literature.
abstract: OBJECTIVE
  Chronic anal fissures are associated with a persistent hypertonia and spasm of the internal anal sphincter. Classic treatment is surgical sphincterotomy to reduce the anal tone and eliminate sphincteric spasm. However, concerns have been raised about the incidence of fecal incontinence after surgery. Therefore, pharmacological means to treat chronic anal fissures have been explored.
  
  
  METHODS
  We conducted a literature review on MEDLINE database.
  
  
  RESULTS
  All treatments address the anomaly of a high anal pressure. Several studies have investigated the effect of topical glyceryl trinitrate ointment. Healing rates range from 30% to 86%. Therapy is limited because of a high incidence of moderate to severe headaches in up to 84% of patients. Comparable results are observed after injection of botulinum toxin into the anal sphincter (43-96%). Minor incontinence for flatus and soiling has been reported in up to 12% of patients. Further pharmacological approaches including treatment via calcium channel blockade and treatment with alpha-adrenoceptor antagonists are still at a developmental stage.
  
  
  CONCLUSIONS
  Topical glyceryl trinitrate ointment and injection of botulinum toxin into the anal sphincter are advocated as the first-line treatment for chronic anal fissure. Lateral sphincterotomy should be offered to patients with relapse and therapeutic failure of prior pharmacological treatment.
authors.affiliation: Department of General, Vascular, and Thoracic Surgery, Benjamin Franklin Medical Center, Freie Universität Berlin, Berlin, Germany.
authors.forename: M J
authors.initials: MJ
authors.lastname: Utzig
authors.forename: A J
authors.initials: AJ
authors.lastname: Kroesen
authors.forename: H J
authors.initials: HJ
authors.lastname: Buhr
mesh_terms: D000287:Administration, Topical; D018726:Anti-Dyskinesia Agents / Q000627:therapeutic use; D001905:Botulinum Toxins / Q000627:therapeutic use; D002121:Calcium Channel Blockers / Q000627:therapeutic use; D002908:Chronic Disease; D002986:Clinical Trials as Topic; D005401:Fissure in Ano / Q000188:drug therapy* / Q000209:etiology*; D006801:Humans; D009569:Nitric Oxide / Q000627:therapeutic use; D005996:Nitroglycerin / Q000627:therapeutic use; D016896:Treatment Outcome; D014665:Vasodilator Agents / Q000627:therapeutic use
chemical_list: D018726:Anti-Dyskinesia Agents; D002121:Calcium Channel Blockers; D014665:Vasodilator Agents; D009569:Nitric Oxide; D001905:Botulinum Toxins; D005996:Nitroglycerin