Randomised Prospective Controlled Trial of Topical 2 % Diltiazem Versus Lateral Internal Sphincterotomy for the Treatment of Chronic Fissure in Ano Comparative study of lateral internal sphincterotomy versus local 0.2% glyceryl trinitrate ointment for the treatment of chronic anal fissure. Comparison of controlled-intermittent anal dilatation and lateral internal sphincterotomy in the treatment of chronic anal fissures: a prospective, randomized study. [Mucosa advancement flap anoplasty in treatment of chronic anal fissures: a prospective, multicenter, randomized controlled trial]. The effect of topical nifedipine in treatment of chronic anal fissure. Internal sphincterotomy versus topical nitroglycerin ointment for chronic anal fissure. Comparative Study of Glyceryl Trinitrate Ointment Versus Surgical Management of Chronic Anal Fissure Surgical treatment of chronic fissure-in-ano: a prospective randomised study. A Study of Fecal Incontinence in Patients with Chronic Anal Fissure: Prospective, Randomized, Controlled Trial of the Extent of Internal Anal Sphincter Division During Lateral Sphincterotomy Anal dilatation versus left lateral sphincterotomy for chronic anal fissure: a prospective randomized study Randomized clinical trial of transcutaneous electrical posterior tibial nerve stimulation versus lateral internal sphincterotomy for treatment of chronic anal fissure. Solcoderm as alternative conservative treatment for acute anal fissure: a controlled clinical study. Incontinence After Lateral Internal Sphincterotomy: A Prospective Study and Quality of Life Assessment Comparative Study of Conventional Lateral Internal Sphincterotomy, V-Y Anoplasty, and Tailored Lateral Internal Sphincterotomy with V-Y Anoplasty in the Treatment of Chronic Anal Fissure A randomized trial of glyceryl trinitrate ointment and nitroglycerin patch in healing of anal fissures Anterior Levatorplasty for the Treatment of Chronic Anal Fissures in Females With a Rectocele: A Randomized, Controlled Trial [Surgical or biologic sphincterotomy in the treatment of chronic anal fissure].
Fissure in ano is a very common disorder of the anorectal region . Internal sphincter hypertonia with decreased relaxation coupled with mucosal ischemia of posterior anal canal are the major pathologies in chronic anal fissure ( CAF ) . Though lateral internal sphincterotomy ( LIS ) remains the gold st and ard of treatment for the disease , it is accompanied by the potential complication of incontinence to both flatus and faecal matter . The aim of our study was to explore the role of topical diltiazem as an effective and a safe alternative to sphincterotomy for chronic anal fissure . Ninety patients with CAF were r and omly assigned to group A and group B , with 45 patients each . Group A patients received 2 % diltiazem topical application , twice daily , and group B patients underwent LIS . All the patients were review ed at first , fourth and sixth week after initiation of treatment . Visual analogue scores for pain and healing of fissure by visual inspection were recorded and compared . In group A , 71 % had complete healing of fissure at 6 weeks , with fair amount of pain relief ( mean VAS—3.38 ) , and in group B , 96 % showed healing of fissure , with excellent pain relief ( mean VAS—1.87 ) . Headache and flushing were noted in two patients in group A while no patients in group B developed incontinence . We conclude that LIS is more effective than topical diltiazem in the treatment of CAF . Topical diltiazem may be employed as an initial conservative treatment option before considering the surgical alternative The gold st and ard surgical treatment of chronic anal fissure is lateral internal sphincterotomy which lowers the resting anal pressure and effectively heals the majority of fissures . Local application of 0.2 % glyceryl trinitrate ointment has been used as an agent for chemical sphincterotomy , causing temporary alleviation of sphincter spasm and allowing the fissure to heal without compromising the anal continence . The aim of the present study was to compare the results of surgical sphincterotomy with that of local 0.2 % glyceryl trinitrate ointment in the treatment of chronic anal fissure . Seventy adult patients between the age of 18 and 50 years with chronic anal fissure were r and omized in a prospect i ve trial to receive either surgical sphincterotomy or 0.2 % glyceryl trinitrate ointment locally . Patients were followed up at 2 weeks ' interval for 10 weeks . Symptom relief , fissure healing and continence scores were the outcomes assessed . Six patients were excluded for protocol violations .  Surgical sphincterotomy was significantly more effective in providing pain relief and was associated with significantly better fissure healing rates at 6 weeks and 10 weeks ( both p < 0.001 ) . There were substantial problems with compliance in ointment group related to slow healing and longer time needed for symptomatic relief . Minor incontinence was 6 % in sphincterotomy group and none in ointment group ( p > 0.05 ) . Considering early symptomatic relief , rapid fissure healing and better patient compliance  surgical sphincterotomy is the treatment of choice for chronic anal fissure AIM The results of controlled-intermittent anal dilatation ( CIAD ) or lateral internal sphincterotomy ( LIS ) in the treatment of chronic anal fissures are presented . MATERIAL AND METHODS Forty patients who were r and omized to two groups underwent CIAD or a LIS .  The pre- and post-operative mean anal canal resting pressures ( MACRPs ) and symptoms were recorded and the results were compared . RESULTS Two months post-operatively , 18 patients in the CIAD group and 17 patients in the LIS group had healed completely , and had no anal incontinence or other complications . The post-operative improvement in pain , bleeding , and constipation did not differ significantly between the two groups . In the CIAD and LIS groups , the pre-operative MACRPs were 89.7+/-16.5 and 87.6+/-12.3 mmHg , respectively ; 2 months post-operatively , the MACRPs had significantly decreased to 76.9+/-13.7 and 78.1+/-11.3 mmHg in the CIAD and LIS groups , respectively . No statistical difference existed in the pre- or post-treatment MACRPs between the groups . CONCLUSION CIAD applied with a st and ardized technique reduced anal canal resting pressure and provided symptomatic healing that was equivalent to a LIS . Since there were no findings of incontinence , or situations which result ed in sphincter damage , we conclude that CIAD is suitable for patients with chronic anal fissures because it is less invasive than LIS , with equivalent efficacy and safety . In addition , the CIAD method may be an alternative procedure in older and multiparous women who has a higher risk of incontinence BACKGROUND Anal fissure is one of the most common anal-rectum diseases , and approximately 10 percent patients with chronic anal fissure ultimately receive surgery . Relieving postoperative pain and protecting functions of the sphincter are central issues for coloproctologists . OBJECTIVE To evaluate the efficacy and safety of anoplasty in the treatment of chronic anal fissures . DESIGN , SETTING , PARTICIPANTS AND INTERVENTIONS In this prospect i ve , multicenter , r and omized controlled trial , 120 adult patients with chronic anal fissure were referred from Department of Coloproctology of Yueyang Hospital of Integrated Traditional Chinese Medicine Affiliated to Shanghai University of Traditional Chinese Medicine , Shanghai Ninth People 's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine and Shanghai Municipal Hospital of Traditional Chinese Medicine . The patients were enrolled from January 2009 to April 2010 and r and omly divided into study ( mucosa advancement flap anoplasty , abbreviated as anoplasty ) group and control ( fissurectomy ) group . The two groups were assessed separately , and the main outcome measures were observed for 2 weeks , with a short-term follow-up for 6 weeks . MAIN OUTCOME MEASURES Degree of pain , haemorrhage and anal canal pressure were observed and recorded preoperatively , and on the third day , the fourteenth day and the sixth week postoperatively . The wound healing time was also recorded . Surgical complications of the two groups were recorded and compared on the third day and the sixth week postoperatively . The curative effects associated with the surgery were analyzed on the fourteenth day and the sixth week after surgery and the therapeutic results were evaluated . RESULTS Three patients were dropped out due to the early discharge from hospital and losing connection ( 1 in study group and 2 in control group ) . Overall the surgery showed that the anoplasty group had better results than the fissurectomy group in the curative effect on the sixth week after operation ( P<0.05 ) . Time of wound healing in the anoplasty group was ( 17.22 ± 4.41 ) d and was better than ( 21.24 ± 7.44 ) d of the fissurectomy group ( P<0.05 ) . Concerning the relief of wound pain , the anoplasty group achieved better results than the fissurectomy group at the third day , the fourteenth day and the sixth week after operation ( P<0.05 ) . Anoplasty reduced bleeding and had better efficacy than the fissurectomy at the third day and the fourteenth day after operation ( P<0.05 ) , however , there was no statistical difference at the sixth week after operation ( P>0.05 ) . There were no significant differences in relieving the anal canal pressure ( P>0.05 ) and the surgical complications ( dysuria , edema of anal margin , fever , infection , anal incontinence and anal deformation ) between the two groups ( P>0.05 ) . None of the patients suffered postoperative complications by the sixth week after operation . Furthermore , there was no recurrence in either of the two groups at six weeks after operation . CONCLUSION The results indicate that anoplasty for chronic anal fissures has advantages such as better therapeutic effects , less postoperative pain , a shorter healing time and no incidence of anal incontinence Chronic anal fissure is the most common cause of anal pain associated with internal anal sphincter hypertonia . Reduction of hypertonocity is a special treatment for fissure healing . For this purpose chronic anal fissures were conventionally treated by anal dilatation or by lateral sphincterotomy . However , both of these methods may cause a degree of incontinence in some patients . The uptake of medical therapies that create a reversible chemical sphincterotomy has recently become widespread . The aim of this prospect i ve clinical trial study was to assess the effectiveness of nifedipine  in healing anal fissure , a calcium channel blocker that reduces sphincter pressure . A single-blind r and omized comparative trial was setup to compare traditional treatment with stool softeners and 2 % lidocaine cream against 0.5 % nifedipine cream for 4 weeks . 110 patients were included in this study , 60 patients in the nifedipine group and 50 patients in the control group and the therapeutic outcome and side effects were recorded . Healing had occurred in 70 % of patients in the nifedipine group and in 12 % of patients in the control group after 4 weeks treatment ( P < 0.005 ) . Recurrence of symptoms occurred in four of healed patients in the nifedipine group and three patients in the control group in two months . The final result of nifedipine application after 12 months follow up was recurrence in 11 patients ( 26.19 % ) . Mild headache occurred in four patients ( 6.6 % ) of the nifedipine group . Patients in the nifedipine group showed significant healing and relief from pain compared with patients in the control group . Recurrence rate with nifedipine use in spite of control of predisposing factors such as constipation was significant . Another finding was low complication rate with this treatment BACKGROUND Anal fissure is a common benign condition . An anorectal problem is defined as a split in the anal canal mucosa that extends from the dentate line to the anal verge . Chronic anal fissure is defined by a history of symptoms present for more than 2 months ' duration and with a triad of external skin tags , namely , a hypertrophied anal papilla , an ulcer with rolled edges , and a base exposing the internal sphincter . Because complications such as incontinence are associated with surgical treatment , chemical sphincterotomy is currently favored . OBJECTIVES The objective of this study is to compare the difference in outcome between open partial lateral anal sphincterotomy and application of topical 0.2 % nitroglycerin ointment for the treatment of chronic anal fissure . METHODS This was a quasi-experimental study carried out between January 16 , 2007 and January 15 , 2008 in the Surgical Department of Jinnah Hospital , Lahore , Pakistan . Sixty consecutive cases with a clinical diagnosis of chronic anal fissure were recruited in the study . All recruited patients met the study inclusion criteria and were r and omly assigned to one of the two groups . Group A was managed conservatively using topical 0.2 % nitroglycerin ointment , whereas Group B underwent open partial lateral anal sphincterotomy . Both groups were followed up at 1 week , 2 weeks , 4 weeks , and 6 weeks after the treatment . RESULTS All the patients complained of pain . A total of 43 ( 71.7 % ) patients had pain with constipation , whereas 31 ( 51.7 % ) patients had bleeding per rectum . Upon clinical ly examining the anal area , tenderness was elicited in all 60 ( 100 % ) patients . Group A included 30 ( 11 females and 19 males ) cases treated with topical 0.2 % nitroglycerin ointment and Group B included 30 ( 11 females and 19 males ) cases who underwent open partial lateral anal sphincterotomy . In Group A , only 15 patients with fissures were successfully treated ( 50 % ) . By contrast , 28 ( 93 % ) patients with fissures in Group B were successfully treated , and only two ( 7 % ) remained uncured . These two patients ( 6.6 % ) in Group B suffered from incontinence due to flatus and feces as a complication of the procedure . CONCLUSION This quasi-experimental study demonstrates that open partial lateral internal sphincterotomy is superior to topical 0.2 % nitroglycerin application in the treatment of chronic anal fissure , with good symptomatic relief , high rate of healing , fewer side effects , and a very low rate of early continence disturbances Chronic Anal Fissure ( CAF ) is common perineal condition and well-known painful entity . St and ard 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 prospect i ve 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 br and 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 A prospect i ve r and omised study compared anal dilatation ( n = 37 ) , posterior internal sphincterotomy ( n = 21 ) and lateral sphincterotomy ( n = 20 ) in the surgical treatment of chronic anal fissures in 78 consecutive patients . All the operations were performed under general anaesthesia using st and ard techniques . Anal dilatation relieved anal pain early ( immediate relief in 57 % of patients ; the mean pain-days + /- SD of 3.2 + /- 5.4 days ) . Anal fissures after this operation healed in a mean time + /- SD of 20.3 + /- 12.5 days , coming in second place to lateral sphincterotomy . Anal dilatation was followed by insignificant wound infection but its main disadvantage was a high rate of post operative anal incontinence ( in 24.3 % of patients ) . Fissurectomy and posterior internal sphincterotomy was followed by the longest period of post operative anal pain ( mean + /- SD of 32.4 + /- 10 days ) as compared to the other two operations . It was the least favourable operation . Lateral sphincterotomy was followed by early relief of pain ( immediate relief in 95 % of patients ) . It was not followed by wound infection . It had the quickest healing time for the fissures ( a mean + /- SD of 14.7 + /- 8.7 days ) . It was followed by anal incontinence in only one patient . In conclusion lateral sphincterotomy was the most favourable operation and it is perhaps the operation of choice to perform in patients with chronic anal fissures needing surgical treatment Background Troublesome fecal incontinence following a lateral internal sphincterotomy is often attributed to faulty surgical technique . However , it may be associated with coexisting occult sphincter defects . Whether continence is related to the extent of sphincterotomy remains debatable . The aim of the study is to identify fecal incontinence related to chronic anal fissure before and after lateral internal sphincterotomy and its relationship to the extent of internal anal sphincter division . Methods One hundred eight patients with chronic anal fissure were prospect ively studied before and after lateral internal sphincterotomy . A question naire was completed for each patient before and after surgery with regard to any degree of fecal incontinence . Fecal incontinence severity index was assessed using the Clevel and Clinic Incontinence Score .  The patients with preoperative perfect continence were r and omized into two groups ( 46 patients in each group ) : Group 1 underwent traditional lateral internal sphincterotomy ( up to the dentate line ) and Group 2 were underwent a conservative internal anal sphincterotomy ( up to the height of the fissure apex or just below it ) . Results Minor degrees of incontinence were present before surgery in 16 patients ( 14.8 % ) . Results of the r and omized trial revealed that temporary postoperative incontinence was newly developed in 6/92 of patients ( 6.52 % ) who did not have it before surgery . Five of the six ( 10.86 % ) were in Group 1 one ( 2.17 % ) was in Group 2 ( p = 0.039 ) . Persistent incontinence occurred in two in Group 1 ( 4.35 % ) . All of them were females . All have had a history of one or more vaginal deliveries .  Conclusion A mild degree of fecal incontinence may be associated with chronic anal fissure at presentation rather than as a result of internal sphincterotomy . Troublesome fecal incontinence after lateral internal sphincterotomy is uncommon . Sphincterotomy up to the dentate line provided faster pain relief and faster anal fissure healing , but it was associated with a significant postoperative alteration in fecal incontinence than was sphincterotomy up to the fissure apex . Care should be exercised in female patients with a history of previous obstetric trauma , as internal anal sphincter division may further compromise sphincter function Background Several surgical methods are accepted for the treatment of chronic anal fissure . The most popular are anal dilatation ( AD ) and left lateral sphincterotomy ( LLS ) . The objective of the current study was to prospect ively evaluate the results of these two procedures in terms of recurrence rate , complications and patient satisfaction . Methods The study enrolled all patients who required operation for chronic anal fissure in the Division of General Surgery , Campus Golda , Rabin Medical Center , between the years 1997 and 2001 . Exclusion criteria were acute anal fissure or inflammatory bowel disease . Results A total of 108 patients participated in the study , at an average age of 42.4 years ( SD=12.5 ) . The patients were r and omly assigned to two groups ; one for LLS ( 53 patients , 49.1 % ) and one for AD ( 55 patients , 50.9 % ) . The study protocol included a question naire and a physical examination performed 1 , 2 , 3 , 6 and 12 months after operation . The question naire contained questions about pain , bloody stool , incontinence for gas , fluid or hard feces , during the day or night , and soiling . The patients were also asked about their satisfaction on an analog scale from 1 to 10 . The average follow-up was 11.2 months ( SD=4.1 ) . Minor incontinence occurred in 8 patients of AD group and in 2 patients of LLS group ( p<0.005 ) . Recurrence occurred in 6 cases of the AD group and in one case of the LLS group ( p<0.003 ) . Satisfaction score was insignificantly higher in the LLS group ( 9.1±0.8 in the LLS group and 7.4±2.0 in the AD group ) . Conclusions These results suggest that LLS is the preferred method for the treatment for chronic anal fissure OBJECTIVES The objective of this study was to evaluate the efficacy of transcutaneous electrical posterior tibial nerve stimulation in treatment of patients with chronic anal fissure and to compare it with the conventional lateral internal sphincterotomy . PATIENTS AND METHODS Consecutive patients with chronic anal fissure were r and omly allocated into two treatment groups : transcutaneous electrical posterior tibial nerve stimulation group and lateral internal sphincterotomy group . The primary outcome measures were number of patients with clinical improvement and healed fissure . Secondary outcome measures were complications , VAS pain scores , Wexner 's constipation and Peascatori anal incontinence scores , anorectal manometry , and quality of life index . RESULTS Seventy-three patients were r and omized into two groups of 36 patients who were subjected to transcutaneous electrical nerve stimulation and 37 patients who underwent lateral internal sphincterotomy . All ( 100 % ) patients in lateral internal sphincterotomy group had clinical improvement at one month following the procedure in contrast to 27 ( 75 % ) patients in transcutaneous electrical nerve stimulation group . Recurrence of anal fissure after one year was reported in one ( 2.7 % ) and 11 ( 40.7 % ) patients in lateral internal sphincterotomy and transcutaneous electrical nerve stimulation groups respectively . Resting anal pressure and functional anal canal length were significantly reduced after lateral internal sphincterotomy . CONCLUSION Transcutaneous electrical posterior tibial nerve stimulation for treatment of chronic anal fissure is a novel , non-invasive procedure and has no complications . However , given the higher rate of clinical improvement and fissure healing and the lower rate of fissure recurrence , lateral internal sphincterotomy remains the gold st and ard for treating chronic anal fissure Acute anal fissure is a common malady that results in morbidity . If a patient is not responsive to conservative treatment , the current recommended treatments are either anal dilatation or lateral internal sphincterotomy . Both operations promise relatively good results , but the recurrence rates are about 16 per cent and 7 per cent , respectively . This fact , together with possible postoperative complications and costs , justifies trying conservative treatment before referring patients for surgery . The authors treated a study group of 25 patients with a topical application of Solcoderm . Another group of 25 patients concurrently treated with the usual conservative treatment served as the control group . Analysis of the early and late results proved Solcoderm to be simple to use , safe , without systemic side effects , cost-effective , and with statistically significant better outcome . Consequently , the authors believe that this method of treatment is justified in cases of acute and fissure and should be attempted before operation PURPOSE : Lateral internal sphincterotomy is an effective treatment for chronic anal fissures ; however , the risk of “ incontinence ” has generated interest in pharmacologic approaches that are far less effective and may be poorly tolerated . This study was design ed to objective ly define the risk of incontinence with sphincterotomy using the Fecal Incontinence Severity Index and assess the implication s for quality of life using the Fecal Incontinence Quality of Life Scale . METHODS : A prospect i ve study was undertaken on all patients undergoing lateral internal sphincterotomy for a chronic anal fissure by a single surgeon at a university teaching hospital from January 1 , 2000 to September 30 , 2002 . All patients had failed at least six weeks of nonoperative management . Patient demographics and use of nitroglycerin were noted . The Fecal Incontinence Severity Index was measured preoperatively and at a six-week postoperative visit when fissure healing and postoperative complications were assessed . The Fecal Incontinence Quality of Life Scale was administered to patients with an incontinence score > 0 . RESULTS : Thirty-five patients ( 15 males ) underwent sphincterotomy during the study period . Thirty-one of 35 had failed nitrates : 10 because of unacceptable side effects , and 21 because of lack of efficacy . Thirty-two patients returned for their six-week postoperative visits , and two completed their question naires by telephone . One patient was lost to follow-up . Mean age was 41.2 ( range , 21–67 ) years . Thirty of 32 ( 94 percent ) evaluable fissures had healed by six weeks , one healed by three months , and the other required V-Y anoplasty . There were two minor complications . Three patients had postoperative deterioration in their continence score . Quality of life deteriorated in only one patient . CONCLUSIONS : Lateral internal sphincterotomy is a safe and effective treatment for chronic anal fissures that only occasionally impairs continence and rarely diminishes quality of life Background Lateral internal sphincterotomy has been proven highly effective in curing anal fissure but with a high incidence of postoperative incontinence . Objective We compared conventional lateral internal sphincterotomy , V-Y advancement flap , and combined tailored lateral internal sphincterotomy with V-Y advancement flap in treating anal fissure . Patients Consecutive patients treated for anal fissure at our colorectal unit were evaluated for inclusion . Participants were r and omly allocated to receive conventional sphincterotomy ( GI ) , V-Y advancement flap ( GII ) , or combined tailored lateral sphincterotomy with V-Y advancement l flap (GIII).Main Outcome Measures The primary outcome measure was the incontinence rate ; secondary outcomes included healing rate , operative time , anal manometery , and recurrence rate . Results One hundred fifty patients with chronic anal fissure were r and omized . Healing rate after 1 year was 84 % in GI , 48 % in GII , and 94 % in GIII , respectively ( P = 0.001 ) . The recurrence rate was 4 % in G1 , 22 % in GII , and 2 % in GIII ( P = 0.01 ) . Incontinence rate was 14 % in GI , 0 % in GII , and 2 % in GIII ( P = 0.03 ) . Conclusion Although all three procedures are simple and easy to perform , tailored lateral internal sphincterotomy with V-YF appears to produce the greatest healing rate , with the fewest complications and less rate of recurrence Abstract . Mean maximum anal resting pressure is directly related to the activity of the smooth muscles of the internal and external sphincters and has been found to be increased in the patients of anal fissure . It has been shown that blood flow at the posterior midline of anoderm is inversely related to the mean maximum anal resting pressure , and topical application of glyceryl trinitrate ( GTN ) ointments is a very successful treatment . This r and omized study was design ed to evaluate the relative value of a nitroglycerin patch applied at a distance from the fissure site in healing anal fissure compared to GTN ointment and compared to surgical treatment .  Forty-two consecutive patients with chronic anal fissure of more than 4 months ' duration were r and omized into two equally sized groups : those in group A received 0.2 % GTN ointment while those in group B received a 10-mg nitroglycerin patch for 8 weeks . Patients were also asked to rate their pain intensity on a scale of 0–10 . Five patients were excluded for various reasons ; results were analyzed for the remaining 37 patients ( group A , n=18 ; group B , n=19 ) . A control group C consisted of 12 patients who underwent surgical treatment . Fissures healed completely in 12 of 18 ( 66.7 % ) patients in group A , 12 of 19 ( 63.2 % ) in group B and 11/12 ( 91.7 % ) in group C. The healing rates in groups A and B did not differ significantly ( P=0.7 ) , nor was there a difference between these and surgical group C ( P=0.13 ) . The local application of GTN ointment and the nitroglycerin patch are both effective , economical , and alternative treatment options for most patients with anal fissures PURPOSE : It is postulated that an anterior anal fissure can result from mucosal trauma occurring during distention of a rectocele and that repair of the rectocele by anterior levatorplasty can lead to healing of these anal fissures . This study was design ed to compare anterior levatorplasty with internal sphincterotomy for the management of anterior anal fissures in females with a rectocele . METHODS : From June 2000 until May 2002 , 54 consecutive females with an anterior anal fissure and a rectocele were r and omized to be managed by internal sphincterotomy or anterior levatorplasty . Preoperatively , manometry was performed , continence was measured using the Clevel and Clinic scoring system , pain scores were obtained using a visual analog scale , and the symptoms of bleeding and straining to defecate were assessed . Postoperatively , pain scores were obtained at Days 2 , 7 , and 21 . Manometry , continence scores , and resolution of symptoms were measured between 8 and 12 weeks . Patient satisfaction and fissure healing also were assessed between 8 and 12 weeks . The average length of follow-up was 20 ( range , 6–30 ) months . RESULTS : Postoperatively , lateral sphincterotomy caused a decrease in the resting pressures and anterior levatorplasty result ed in an increased length of the anal canal . Anterior levatorplasty also caused increased postoperative pain scores . There were no differences in fissure healing and patient satisfaction . CONCLUSIONS : These data suggest that anterior levatorplasty is an option for the management of patients with a rectocele , which may avoid the risk of incontinence with lateral internal sphincterotomy and better address the etiology of anterior anal fissures BACKGROUND Chronic anal fissure is a lineal ulcer of the lower part of the anal canal . It is a painful condition characterized by postdefecational pain and bleeding . It is associated with internal anal sphincter spasm . The relief of internal anal sphincter spasm is the key for providing fissure healing . Gold st and ard in the treatment of chronic anal fissure is partial lateral internal anal sphincterotomy . METHODS Sixty patients with chronic anal fissure were r and omly assigned into two groups treated either by surgical sphincterotomy or injections of botulinum toxin into internal anal sphincter .  Manometric measurements were performed before and three months after treatment . Follow up period was six months . The aim of the study was to compare results between these two groups . RESULTS Both methods efficiently reduced resting anal pressure and successfully healed chronic anal fissure . CONCLUSION Surgical and biologic sphincterotomy are almost equally effective in the treatment of chronic anal fissure . Injecting botulinum toxin into internal anal sphincter is a safe , easy to apply and effective method in the management of anal fissure
Botox and CCBs were equivalent to GTN in efficacy with fewer adverse events .
No medical therapy came close to the efficacy of surgical sphincterotomy , though none in these RCTs was associated with the risk of incontinence .
Medical therapy for chronic anal fissure , acute fissure and fissure in children may be applied with a chance of cure that is marginally better than placebo , and , for chronic fissure in adults , far less effective than surgery
BACKGROUND Because of the disability associated with surgery for anal fissure and the risk of incontinence , medical alternatives for surgery have been sought .
Most recently , pharmacologic methods that relax the anal smooth muscle , to accomplish reversibly what occurs in surgery , have been used to obtain fissure healing .
OBJECTIVES To assess the efficacy and morbidity of various medical therapies for anal fissure .