title: Nonsurgical treatment of chronic anal fissure: nitroglycerin and dilatation versus nifedipine and botulinum toxin.
abstract: BACKGROUND
  Surgical sphincterotomy for chronic anal fissure can cause fecal incontinence. This has led to the investigation of nonsurgical treatment options that avoid permanent damage to the internal anal sphincter.
  
  
  METHODS
  We conducted a retrospective, ongoing chart review with telephone follow-up of 88 patients treated for chronic anal fissure between November 1996 and December 2002. During the first half of the study period, patients were treated with topical nitroglycerin and pneumatic dilatation. With the availability of new therapies in June 1999, subsequent patients received topical nifedipine and botulinum toxin injections (30-100 units). Lateral anal sphincterotomy was reserved for patients who failed medical treatment.
  
  
  RESULTS
  In 98% of patients the fissure healed with conservative nonsurgical treatment. The combination of nifedipine and botulinum toxin was superior to nitroglycerin and pneumatic dilatation with respect to both healing (94% v. 71%, p < 0.05) and recurrence rate (2% v. 27%, p < 0.01). There was no statistical difference between the number of dilatations and botulinum toxin injections needed to achieve healing. Three patients who received botulinum toxin reported mild transient flatus incontinence. At an average telephone follow-up of 27 months, 92% of patients reported having no pain or only mild occasional pain with bowel movements.
  
  
  CONCLUSIONS
  Chronic anal fissures can be simply and effectively treated medically without the risk of incontinence associated with sphincterotomy. Topical nifedipine and botulinum toxin injections are an excellent combination, associated with a low recurrence rate and minimal side effects.
authors.affiliation: Division of General Surgery, University of Ottawa, The Ottawa Hospital - General Campus, Ottawa. ptranqui@hotmail.com
authors.forename: Philippe
authors.initials: P
authors.lastname: Tranqui
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Trottier
authors.forename: Charles
authors.initials: C
authors.lastname: Victor
authors.forename: Joel B
authors.initials: JB
authors.lastname: Freeman
mesh_terms: D000287:Administration, Topical; D000328:Adult; D018726:Anti-Dyskinesia Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D001905:Botulinum Toxins / Q000008:administration & dosage / Q000627:therapeutic use*; D002404:Catheterization / Q000379:methods*; D002908:Chronic Disease; D005260:Female; D005401:Fissure in Ano / Q000628:therapy*; D005500:Follow-Up Studies; D006801:Humans; D007273:Injections, Intramuscular; D008297:Male; D008875:Middle Aged; D009543:Nifedipine / Q000008:administration & dosage / Q000627:therapeutic use*; D005996:Nitroglycerin / Q000008:administration & dosage / Q000627:therapeutic use*; D017060:Patient Satisfaction; D012189:Retrospective Studies; D016896:Treatment Outcome; D014665:Vasodilator Agents / Q000008:administration & dosage / Q000627:therapeutic use*
chemical_list: D018726:Anti-Dyskinesia Agents; D014665:Vasodilator Agents; D001905:Botulinum Toxins; D005996:Nitroglycerin; D009543:Nifedipine