title: Randomized clinical trial comparing oral nifedipine with lateral anal sphincterotomy and tailored sphincterotomy in the treatment of chronic anal fissure A prospective randomized trial betwen subcutaneous lateral internal sphincterotomy with radiofrequency bistoury and conventional parks' operation in the treatment of anal fissures. Randomized, Prospective Trial Comparing 0.25 Percent Glycerin Trinitrate Ointment and Anal Cryothermal Dilators Only with 0.25 Percent Glycerin Trinitrate Ointment and Only with Anal Cryothermal Dilators in the Treatment of Chronic Anal Fissure: A Two-Year Follow-Up A perfect correlate does not a surrogate make A randomized trial of glyceryl trinitrate ointment and nitroglycerin patch in healing of anal fissures Topical anal fissure treatment: placebo-controlled study of mononitrate and trinitrate therapies Hydropneumatic anal dilation in conservative treatment of chronic anal
  fissure: clinical outcomes and randomized comparison with topical
  nitroglycerin A prospective randomized trial of diltiazem and glyceryltrinitrate ointment in the treatment of chronic anal fissure Treatment of first episodes of acute anal fissure: prospective randomised study of lignocaine ointment versus hydrocortisone ointment or warm sitz baths plus bran. Maintenance Therapy with Unprocessed Bran in the Prevention of Acute Anal Fissure Recurrence A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure Internal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure A Comparison of the Effects of Diltiazem and Glyceryl Trinitrate Ointment in the Treatment of Chronic Anal Fissure: A Randomized Clinical Trial Efficacy and Safety of Botulinum Toxin A Injection Compared with Topical Nitroglycerin Ointment for the Treatment of Chronic Anal Fissure: A Prospective Randomized Study Comparison of Topical Glyceryl Trinitrate Ointment and Oral Nifedipine in the Treatment of Chronic Anal Fissure Randomised controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate Botulinum toxin injection versus internal anal sphincterotomy for the treatment of chronic anal fissure Double blind randomised controlled trial of topical glyceryl trinitrate in anal fissure A dose finding study with 0.1%, 0.2%, and 0.4% glyceryl trinitrate ointment in patients with chronic anal fissures Topical mononitrate treatment in patients with anal fissure Topical nitroglycerin versus lateral internal sphincterotomy for chronic anal fissure: prospective, randomized trial Comparison of Glycerine Trinitrate and Botulinum Toxin-A for the Treatment of Chronic Anal Fissure: Long-Term Results The conservative treatment of fissure‐in‐ano Glyceryl trinitrate vs. lateral sphincterotomy for chronic anal fissure: Prospective, randomized trial Topical 0.5% nifedipine vs. lateral internal sphincterotomy for the treatment of chronic anal fissure: long-term follow-up Long-term results of topical nitroglycerin in the treatment of chronic anal fissures are disappointing Incontinence After Lateral Internal Sphincterotomy: A Prospective Study and Quality of Life Assessment Randomized prospective controlled trial of lateral internal sphincterotomy versus injection of botulinum toxin for the treatment of idiopathic fissure in ano [A prospective, randomized double-blind study on the treatment of anal fissures with Nitroglycerin ointment]. Surgical versus chemical (botulinum toxin) sphincterotomy for chronic anal fissure: long-term results of a prospective randomized clinical and manometric study. Comparative study of lateral internal sphincterotomy versus local 0.2% glyceryl trinitrate ointment for the treatment of chronic anal fissure. Randomized clinical trial assessing the side‐effects of glyceryl trinitrate and diltiazem hydrochloride in the treatment of chronic anal fissure Double-blind manometric assessment of two topical glyceryl trinitrate formulations in patients with chronic anal fissures. A double‐blind randomized placebo‐controlled trial of oral indoramin to treat chronic anal fissure Chronic anal fissures treated with botulinum toxin injections: a dose‐finding study with Dysport® Topical Nifedipine vs. Topical Glyceryl Trinitrate for Treatment of Chronic Anal Fissure A randomized trial of botulinum toxin vs lidocain pomade for chronic anal fissure. Comparison of topical glyceryl trinitrate with lignocaine ointment for treatment of anal fissure: a randomised controlled trial. Topical Nifedipine With Lidocaine Ointment vs. Active Control for Treatment of Chronic Anal Fissure Controlled Dose Delivery in Topical Treatment of Anal Fissure: Pilot Study of a New Paradigm Topical 0.2% glyceryl trinitrate ointment for anal fissures: long‐term efficacy in routine clinical practice Randomized, prospective trial comparing 0.2 percent isosorbide dinitrate ointment with sphincterotomy in treatment of chronic anal fissure: A two-year follow-up Manometric Effect of Topical Glyceryl Trinitrate and Its Impact on Chronic Anal Fissure Healing A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. Local nitroglycerin for treatment of anal fissures: An alternative to lateral sphincterotomy? Nifedipine for local use in conservative treatment of anal fissures Glyceryl trinitrate for chronic anal fissure—Healing or headache? Effectiveness of higher doses of botulinum toxin to induce healing in patients with chronic anal fissures. The use of glyceryl trinitrate (GTN) in the treatment of chronic anal fissure in children. Randomized, double-blind trial comparing topical nitroglycerine with xylocaine and Proctosedyl in idiopathic chronic anal fissure. 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. Treatment of chronic anal fissure with topical glyceryl trinitrate: a double-blind, placebo-controlled trial. A prospective, randomized, double-blind, placebo-controlled trial of glyceryl-trinitrate ointment in the treatment of children with anal fissure. Lack of effficacy of botulinum toxin in chronic anal fissure Treatment of anal fissures using a combination of minoxidil and lignocaine: a randomized, double-blind trial. The anal dilator in the conservative management of acute anal fissures Glyceryl trinitrate ointment for the treatment of chronic anal fissure Safety and Efficacy of New Glyceryl Trinitrate Suppository Formula: First Double Blind Placebo-Controlled Clinical Trial [Efficacy of anal dilators in the treatment of acute anal fissure. A controlled clinical trial]. Botulinum neurotoxin to treat chronic anal fissure: results of a randomized ‘Botox vs. Dysport’ controlled trial Comparison of Botulinum Toxin Injection and Lateral Internal Sphincterotomy for the Treatment of Chronic Anal Fissure A randomized trial of oralvs. topical diltiazem for chronic anal fissures Randomized, placebo-controlled treatment of anal fissure by lidocaine, EMLA, and GTN in children. [Surgical or biologic sphincterotomy in the treatment of chronic anal fissure]. Lateral internal sphincterotomy is not redundant in the era of glyceryl trinitrate therapy for chronic anal fissure Glyceryl trinitratevs. sphincterotomy for treatment of chronic fissure-in-ano Isosorbide dinitrate in the treatment of anal fissure: a randomised, prospective, double blind, placebo-controlled trial. Influence of botulinum toxin site of injections on healing rate in patients with chronic anal fissure. Randomized Clinical Trial of Botulinum Toxin Plus Glyceryl Trinitrate vs. Botulinum Toxin Alone for Medically Resistant Chronic Anal Fissure: Overall Poor Healing Rates
abstract: The conventional treatment of  chronic anal fissure  is lateral sphincterotomy ( LAS ) . The alternative options of tailored sphincterotomy ( TS ) and ‘ chemical sphincterotomy ’ using medication such as nifedipine have recently become available BACKGROUND Anal fissure is a frequent proctologic disease . There are many and various treatments adopted to cure this disease . In this study we applied radiofrequencies to the subcutaneous lateral internal sphincterotomy and we compared the techniques in a r and omised trial . METHODS Patients have been r and omized in two groups : in group A 18 patients underwent subcutaneous lateral internal sphincterotomy using radiofrequency bistoury while in group B 17 patients underwent the conventional lateral internal sphincterotomy described by Parks .  RESULTS The mean values for operative time were 6.6 min for group A and 9.1 min for group B. According to pain score , patients ' mean values were 1.8 for group A and 1.9 for group B. Healing of the wound was faster in group A than group B , while healing of the anal fissure was approximately the same . CONCLUSION Lateral subcutaneous sphincterotomy is the most advantageous operation for the treatment of the idiopathic anal fissure . The radiofrequency bistoury easies the procedure , lessens operating times and healing process of the surgical wounds Purpose The objective of this study was to compare the efficacy of 0.25 percent glycerin trinitrate ointment in association with cryothermal anal dilators with 0.25 percent glycerin trinitrate ointment only and cryothermal anal dilators only . Methods A total of 48 patients suffering from chronic anal fissure were enrolled in this prospect i ve , r and omized study between January 2002 and December 2003 : Group A , 16 patients were treated with 0.25 percent glycerin trinitrate ointment and also used cryothermal anal dilators ; Group B , 16 patients were treated with 0.25 percent glycerin trinitrate ointment only ; Group C , 16 patients were treated with cryothermal anal dilator use only . All patients in each group followed the specified treatment protocol for six weeks . Results After seven weeks of treatment , the symptoms complained of were resolved in 15 patients ( 93.7 percent ) in Group A , 12 patients ( 75 percent ) in Group B , and 12 patients ( 78 percent ) in Group C. After two years of follow-up , 14 patients ( 87.5 percent ) in Group A , 9 patients ( 56.2 percent ) in Group B , and 10 patients ( 62.5 percent ) in Group C presented no recurrence of symptoms . No patient in any group reported serious side effects of the treatment proposed , and treatment did not have to be withdrawn in any of the r and omized patients . No episodes of anal incontinence of gas or feces were recorded in the patients who had used the anal dilators . Conclusions The combined treatment for chronic anal fissure proved to be efficacious , safe , and with statistically significant better results than the other treatments analyzed Background There is common belief among some medical research ers that if a potential surrogate endpoint is highly correlated with a true endpoint , then a positive ( or negative ) difference in potential surrogate endpoints between r and omization groups would imply a positive ( or negative ) difference in unobserved true endpoints between r and omization groups . We investigate this belief when the potential surrogate and unobserved true endpoints are perfectly correlated within each r and omization group . Methods We use a graphical approach . The vertical axis is the unobserved true endpoint and the horizontal axis is the  potential surrogate endpoint  . Perfect correlation within each r and omization group implies that , for each r and omization group , potential surrogate and true endpoints are related by a straight line . In this scenario the investigator does not know the slopes or intercepts . We consider a plausible example where the slope of the line is higher for the experimental group than for the control group . Results In our example with unknown lines , a decrease in mean potential surrogate endpoints from control to experimental groups corresponds to an increase in mean true endpoint from control to experimental groups . Thus the potential surrogate endpoints give the wrong inference . Similar results hold for binary potential surrogate and true outcomes ( although the notion of correlation does not apply ) . The potential surrogate endpointwould give the correct inference if either ( i ) the unknown lines for the two group coincided , which means that the distribution of true endpoint conditional on potential surrogate endpoint does not depend on treatment group , which is called the Prentice Criterion or ( ii ) if one could accurately predict the lines based on data from prior studies . Conclusion Perfect correlation between potential surrogate and unobserved true outcomes within r and omized groups does not guarantee correct inference based on a potential surrogate endpoint . Even in early phase trials , investigators should not base conclusions on potential surrogate endpoints in which the only validation is high correlation with the true endpoint within a group 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 Aim The present study aims to evaluate and compare the efficacy of two nitrate gels , containing isosorbide-5-mononitrate ( ISMN ) or glyceryl trinitrate ( GTN ) , in the therapy of chronic anal fissure . Material s and methods The patients were r and omly assigned to three groups : 0.1 % ISMN gel ( 21 patients ) , 0.1 % GTN gel ( 21 patients ) and a placebo group ( ten patients ) . The ethic committee of our hospital approved the protocol and informed consent was obtained from all participants . All patients underwent clinical examination , visual inspection of the fissure and anal manometry prior to and after therapy . Results The chronic anal fissure was completely healed in 71 % of the patients treated with ISMN , 67 % with GTN and in 30 % from the placebo group . One patient in the ISMN group reported mild headache . Three patients in the GTN group had anal burning . Conclusion Both topical nitrate treatments ( ISMN and GTN ) were effective for chronic anal fissures . The reduction of the anal pressure was slightly higher after ISMN treatment ( 28 % ) than the treatment with GTN ( 23 % ) . However , the statistical difference was not significant ( p > 0.05 ) Abstract . Background The surgical approach in chronic anal fissures ( CAF ) may , occasionally result in anal incontinence . The aim of this investigation was to study feasibility , effectiveness , and safety of hydropneumatic anal dilation ( HAD ) in conservative treatment of CAF and to compare it with local nitroglycerin ( GTN ) treatment . Methods Efficacy of HAD was evaluated in 109 patients ( 65 male , 44 female ; mean age , 53.3 years ) , following anal dilation using Microvasive Rigiflex instrument ( Otw 40 mm ) . Thereafter , 36 patients were r and omly divided into two groups to undergo treatment with 0.25 % GTN or HAD . Results Recovery rate with HAD was 79.8 % after 10 days and 94.5 % after 30 days . An immediate ( within 24 hours ) drop was observed in the level of pain ; no significant complications or recurrence were reported within 2 years . Healing rate was 94.5 % following HAD vs. 38.9 % after GTN . Conclusion HAD should be considered a new safe option in CAF treatment Objective The aim of this study was to compare prospect ively diltiazem with GTN ointment in the treatment of anal fissure One hundred and three patients with an acute first episode of posterior anal fissure were r and omised to receive a three week trial of lignocaine ointment ( n = 33 ) versus hydrocortisone ointment ( n = 35 ) or warm sitz baths combined with an intake of unprocessed bran ( n = 35 ) . Seven patients were withdrawn owing to failure to adhere to the trial protocol . After one and two weeks of treatment symptomatic relief was significantly better among patients treated with sitz baths and bran than among patients treated with lignocaine ointment or hydrocortisone ointment . After three weeks there was no difference in symptomatic relief among the three groups . Patients treated with lignocaine , however , had significantly fewer healed fissures ( 60 % ) than patients treated with hydrocortisone ( 82.4 % ) or warm sitz baths and bran ( 87 % ) . In this study warm sitz baths plus an intake of unprocessed bran came out as the treatment of choice for an acute first episode of posterior anal fissure . This treatment is cheap , has no potential serious side effects , and brings the best and quickest relief of symptoms The effect of unprocessed bran in a dose of 5 g three times daily and a dose of 2.5 g three times daily for one year on the recurrence rate of anal fissures was studied in a double-blind , placebo-controlled trial in 90 patients with recently healed acute posterior anal fissures . Fifteen patients ( 16.6 % ) were withdrawn before the code was broken due to failure to follow the trial protocol for various reasons . Significantly fewer recurrences occurred in patients receiving bran 5 g throe times daily ( recurrence rate 16 % , 95 % confidence limits , 4.54 to 36.08 ) when compared with patients receiving bran 2.5 g three times daily ( 60 % ; 38.67 to 78.87 ) ( P<0.01 ) and with patients receiving placebo three times daily ( 68 % ; 46.50 to 85.05 ) ( P<0.01 ) . No significant difference in recurrences was found between patients on bran 2.5 g and those on placebo BACKGROUND Anal fissure is most commonly treated surgically by internal anal sphincterotomy . However , there is some concern over the effects of this procedure on continence . Nitric oxide donors such as glyceryl trinitrate ( GTN ) have been shown to cause a reversible chemical sphincterotomy capable of healing fissures in a small series of cases . This study reports a prospect i ve , r and omised , double-blind , placebo-controlled trial to test the hypothesis that topical GTN is the best first-line treatment for chronic anal fissure . METHODS 80 consecutive patients were r and omised to receive treatments with topical 0.2 % GTN ointment or placebo .  Maximum anal resting pressure ( MARP ) was measured with a constantly perfused side-hole catheter before and after the first application of trial ointment . Anodermal blood flow was measured during manometry by laser Doppler flowmetry . After initial treatments , patients were given a supply of ointment ( either GTN or placebo ) to be applied to the lower anal canal twice daily . Patients were review ed 2-weekly . At the initial and follow up visits patients were asked to record pain experienced on defaecation on a linear analogue pain score . Endpoints were healing of the fissure or condition after 8 weeks of treatment . FINDINGS After 8 weeks , healing was observed in 26/38 ( 68 % ) patients treated with GTN and in 3/39 ( 8 % ) patients treated with placebo ( p < 0.0001 , chi 2 test ) . Linear analogue pain score fell significantly in both groups after 2 weeks of treatment . This fall was maintained in those treated with GTN but pain scores returned to pre-treatment values by 4 weeks on treatment with placebo .  MARP fell significantly from a mean of 115.9 ( SD 31.6 ) to 75.9 ( 30.1 ) cm H2O ( p < 0.001 , Student 's paired t-test ) in patients treated with GTN but no change was seen in MARP after placebo .  Anodermal blood flow measured by laser Doppler flowmetry significantly increased after application of GTN ointment but was unaffected by placebo . INTERPRETATION Topical GTN provides rapid , sustained relief of pain in patients with anal fissure . Over two-thirds of patients treated in this way avoided surgery which would otherwise have been required for healing . Long-term follow up is needed to assess the risk of recurrent fissure in patients with GTN PURPOSE : This was a multicenter , r and omized , controlled trial to compare the effectiveness of topical nitroglycerin with internal sphincterotomy in the treatment of chronic anal fissure . METHODS : Patients with symptomatic chronic anal fissures were r and omly assigned to 0.25 percent nitroglycerintid or internal sphincterotomy . Both groups received stool softeners and fiber supplements and were assessed at six weeks and six months . RESULTS : Ninety patients were accrued , but 8 were excluded from the analysis because they refused internal sphincterotomy after r and omization ( 6 ) , the fissure healed before surgery ( 1 ) , or a fissure was not observed at surgery ( 1 ) . There were 38 patients in the internal sphincterotomy group ( 22 males ; mean age , 40.3 years ) and 44 patients in the nitroglycerin group ( 15 males ; mean age , 38.7 years ) . At six weeks 34 patients ( 89.5 percent ) in the internal sphincterotomy group compared with 13 patients ( 29.5 percent ) in the nitroglycerin group had complete healing of the fissure ( P=5 × 10−8 ) . Five of the 13 patients in the nitroglycerin group relapsed , whereas none in the internal sphincterotomy group did . At six months fissures in 35 ( 92.1 percent ) patients in the internal sphincterotomy group compared with 12 ( 27.2 percent ) patients in the nitroglycerin group had healed ( P=3 × 10−9 ) . One ( 2.6 percent ) patient in the internal sphincterotomy group required further surgery for a superficial fistula compared with 20 ( 45.4 percent ) patients in the nitroglycerin group who required an internal sphincterotomy ( P=9 × 10−6 ) . Eleven ( 28.9 percent ) patients in the internal sphincterotomy group developed side effects compared with 37 ( 84 percent ) patients in the nitroglycerin group ( P<0.0001 ) . Nine ( 20.5 percent ) patients discontinued the nitroglycerin because of headaches ( 8) or a severe syncopal attack ( 1 ) . CONCLUSIONS : Internal sphincterotomy is superior to topical nitroglycerin 0.25 percent in the treatment of chronic anal fissure , with a high rate of healing , few side effects , and low risk of early incontinence . Thus , internal sphincterotomy remains the treatment of choice for chronic anal fissure 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 r and omly 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 OBJECTIVES : To evaluate the efficacy and safety of botulinum toxin A injection compared with topical nitroglycerin ointment for the treatment of  chronic anal fissure ( CAF ) . METHODS : Fifty out patients with CAF were r and omized to receive either a single botulinum toxin injection ( 30 IU Botox ® ) or topical nitroglycerin ointment 0.2 % b.i.d . for 2 wk . If the initial therapy failed , patients were assigned to the other treatment group for a further 2 wk . If CAF still showed no healing at wk 4 , patients received combination therapy of botulinum toxin and nitroglycerin for 4 additional wk . Persisting CAF at wk 8 was treated according to the investigator 's decision . Healing rates , symptoms , and side effects of the therapy were recorded at wk 2 , 4 , 8 , 12 , and 24 after r and omization . RESULTS : The group initially treated with nitroglycerin showed a higher healing rate of CAF ( 13 of 25 , 52 % ) as compared with the botulinum toxin group ( 6 of 25 , 24 % ) after the first 2 wk of therapy ( p < 0.05 ) . At the end of wk 4 , CAF healed in three additional patients , all receiving nitroglycerin after initial botulinum toxin injection . Mild side effects occurred in 13 of 50 ( 26 % ) patients , all except one were on nitroglycerin . CONCLUSIONS : Nitroglycerin ointment was superior to the more expensive and invasive botulinum toxin injection for initial healing of CAF , but was associated with more but mild side effects Abstract This study was design ed 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 r and omly 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 review ed 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 BACKGROUND Topical application of glyceryl trinitrate ( GTN ) ointment heals chronic anal fissures , providing an alternative to the traditional first line treatment of surgical sphincterotomy . AIMS To determine the most effective dose of topical GTN for treatment of chronic anal fissures and to assess long term results . METHODS Seventy consecutive patients with chronic anal fissure , were r and omly allocated to eight weeks treatment with placebo , 0.2 % GTN three times daily , or GTN starting at 0.2 % with weekly 0.1 % increments to a maximum of 0.6 % , in a double blind study . RESULTS After eight weeks fissure had healed in 67 % of patients treated with GTN compared with 32 % with placebo ( p=0.008 ) . No significant difference was seen between the two active treatments . Headaches were reported by 72 % of patients on GTN compared with 27 % on placebo ( p<0.001 ) . Maximum anal sphincter pressure reduced significantly from baseline by GTN treatment ( p=0.02 ) , but not placebo ( p=0.8 ) . Mean pain scores were lower after treatment with GTN compared with placebo ( NS ) . Of fissures healed with placebo 43 % recurred , compared with 33 % of those healed with 0.2 % GTN and 25 % healed with escalating dose GTN ( p=0.7 ) . CONCLUSIONS GTN is a good first line treatment for two thirds of patients with anal fissure . An escalating dose of GTN does not result in earlier healing . Significant recurrence of symptomatic fissures and a high incidence of headaches are limitations of the treatment BACKGROUND Anal fissure is a chronic condition characterized by painful defecation and rectal bleeding . The aim of this study was to compare injection of botulinum toxin versus surgical sphincterotomy for treatment of chronic anal fissure . PATIENTS AND METHODS In a quasi-experimental trial in a university hospital in Kerman , 50 patients diagnosed with chronic anal fissure received 20 units botulinum toxin ( n=25 ) or underwent lateral internal sphincterotomy ( n=25 ) . All patients were evaluated for pain , bleeding and healing of the fissure from one to six months later by another surgeon . The data was analyzed by SPSS software with the Mann-Whitney and Fisher ’s exact tests . RESULTS One month after treatment , the rate of healing and bleeding in the operation group was better than in the toxin group ( P<0.05 ) , while pain was equal . After two months , none of the patients in either group had complications . After six months follow-up , bleeding , pain and healing were better in the operation group . CONCLUSION In the clinical evaluation , botulinum toxin is an effective alternative nonsurgical modality for the treatment of chronic anal fissure . We recommend botulinum toxin as the first step in treatment because of the 60 % chance of cure with an easily performed treatment AIMS To determine the effectiveness and safety of topical glyceryl trinitrate ( GTN ) in the management of acute anal fissure in children . METHODS Individual children were r and omised to receive GTN paste or placebo for six weeks in addition to oral senna and lactulose . Patients took laxatives alone for a further 10 weeks . Each week a research nurse telephoned families to assess pain scores and give advice . Main outcome measures were vali date d st and ardised pain scores and time to painless defaecation . RESULTS Forty subjects were recruited from 46 eligible children ; 31 children completed the trial ( 13 in the GTN group and 18 in the placebo group ) . No differences in the proportion of those achieving pain free defaecation with relation to time were seen between the two groups . Similarly , there were no significant differences in pain scores between the two groups over the 16 week study period . However , in both groups pain scores had decreased significantly . There were no differences in the incidence of rectal bleeding , faecal soiling , presence of visible fissure , skin tag , or faecal loading at outpatient review at the time of recruitment , or at 6 weeks and 16 weeks . No serious adverse effects were observed . CONCLUSIONS This study suggests that 0.2 % GTN paste is ineffective in the treatment of acute anal fissures in childhood . However the overall fissure healing rate is high ( 84 % ) with associated reduction in pain scores , suggesting that a nurse based treatment programme can achieve a high rate of fissure healing Background : Anal fissure is a common painful condition affecting the anal canal . The majority of acute fissures heal spontaneously . However , some of these acute fissures do not resolve but become chronic . Chronic anal fissures were traditionally treated by anal dilation or by lateral sphincterotomy . However , both of these surgical treatments may cause a degree of incontinence in up to 30 % of patients . Several recent trials have shown that nitric oxide donors such as glyceryl trinitrate ( GTN ) can reduce sphincter pressure and heal up to 70 % of chronic fissures . Aim : This study addressed the dose-response to three different concentrations of GTN ointment compared with placebo in a double blind r and omised controlled trial . Method : A double blind , multicentre , r and omised controlled trial was set up to compare placebo ointment against three active treatment arms ( 0.1 % , 0.2 % , and 0.4 % GTN ointment applied at a dose of 220 mg twice daily ) in chronic anal fissures . The primary end point was complete healing of the fissure . Results : Two hundred patients were recruited over an eight month period from 18 centres . After eight weeks of treatment the healing rate in the placebo group was 37.5 % compared with 46.9 % for 0.1 % , 40.4 % for 0.2 % , and 54.1 % for 0.4 % GTN . None was significantly better than the placebo response . A secondary analysis excluded fissures without secondary criteria for chronicity . Healing rates were then found to be 24 % in the placebo group compared with 50 % in the 0.1 % GTN group , 36 % in the 0.2 % group , and 57 % in the 0.4 % GTN group . These values were statistically significantly different for the placebo group compared with 0.1 % GTN , 0.4 % GTN , and for the GTN treated group as a whole . Conclusions : The results of this study have demonstrated the significant benefit of topical GTN when applied to patients suffering from chronic anal fissures but acute fissures showed a tendency to resolve spontaneously . The high proportion of fissures which healed in the placebo group suggests that the definition of “ chronicity ” needs to be reassessed . Further studies are required to confirm the optimal therapeutic strategy To assess the efficacy and patient compliance of topical mononitrate hydrogel for the treatment of anal fissure Introduction : Topical nitroglycerin ( GTN ) is one of the medical treatments of choice in chronic anal fissure . The present prospect i ve , r and omized , 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 Purpose This study was design ed to compare the efficacy of two different “ chemical sphincterotomies ” for chronic anal fissure . Methods From January to December 2001 , 30 consecutive patients ( 17 males ; mean age , 41.8 years ) with chronic posterior anal fissure were enrolled . The patients were r and omly assigned to receive 0.2 percent glycerine trinitrate ointment applied three times daily at theanal margin for eight weeks ( Group A ) or 20 units Botulinum toxin A injection into the internal anal sphincter on each side of the anterior midline ( Group B ) . The patients were review ed at 15 days , 1 , 3 , 6 , 12 , and every other 12 months . Follow-up ranged between 36 and 46 months . Patients in either group who failed to improve were referred for surgical treatment . Results Twelve patients in Group A and 11 in Group B had improvement or relief from symptoms at the first visit . The fissure was healed in ten patients in Group A and in eight in Group B within three months ( 66.7 and 57.1 percent ) . Recurrence of the fissure occurred in five patients in each group during the follow-up . The healing rate at three years was 40 and 33.3 percent for Group A and B , respectively . No patients in either group reported serious adverse effects ; however , three patients in Group A ( 20 percent ) had transient headache . None had fecal incontinence . Conclusion Both treatments may be considered as first-line treatment even if less effective than surgery A r and omized clinical trial assessed the value of regular anal dilatation in combination with a topical local anaesthetic in the treatment of 82 patients with a posterior fissure‐in‐ano . One month after treatment the fissure had healed in 43·6 per cent of patients using 2 per cent lignocaine gel alone and in 41·9 per cent of patients who also used a St Mark 's Hospital anal dilator . Thus the regular use of such a dilator did not contribute to the success of conservative therapy in patients with a posterior anal fissure . A review of patients who presented with anterior or lateral anal fissures during the trial period revealed that healing was achieved in 73·3 per cent of patients without operation within 1 month of diagnosis INTRODUCTION : Glyceryl trinitrate has been shown to be an effective treatment for  chronic anal fissure .  It decreases anal tone and ultimately heals anal fissures . The aim of this trial was to compare glyceryl trinitrate with lateral sphincterotomy ( current st and ard treatment ) as definitive management for  chronic anal fissure . METHODS : All patients with symptoms of chronic anal fissure were r and omly assigned to one of two treatment arms . The glyceryl trinitrate group applied 0.2 percent paste to the perianal area three times a day for eight weeks . Patients in the lateral sphincterotomy group underwent surgery on the next available operating list . Patients were review ed at two weekly intervals until the fissure healed . RESULTS : Sixty‐five patients were enrolled in the trial , with 31 in the lateral sphincterotomy group and 34 in the glyceryl trinitrate group . Five patients were excluded after r and omization . Twenty of 33 ( 60.6 percent ) glyceryl trinitrate patients had healed fissures in eight weeks compared with 26 of 27 ( 97 percent ) in the sphincterotomy group ( P = 0.001 ) . Twelve patients in the glyceryl trinitrate group had little improvement in their symptoms and underwent lateral sphincterotomy .  Poor tolerance and poor compliance with treatment were important factors in patients whose fissures did not heal with glyceryl trinitrate .  Fissures healed significantly faster after sphincterotomy compared with glyceryl trinitrate treatment ( P = 0.0001 ) . Nine of the 20 patients whose fissures healed with glyceryl trinitrate paste subsequently had a recurrence of their fissures . There were no long‐term complications from lateral sphincterotomy . CONCLUSION : Glyceryl trinitrate paste heals the majority of chronic anal fissures . However , a significant minority have little improvement or develop side effects and require conventional surgical treatment . Poor compliance with prescribed treatment often contributes to nonhealing . In addition , some fissures which initially heal with glyceryl trinitrate paste recur and require further treatment . Glyceryl trinitrate treatment is labor intensive for patients and physicians and has not been shown to be superior to lateral sphincterotomy Background The aim of this study was to compare the efficacy of the local application of 0.5 % nifedipine ointment vs. lateral internal sphincterotomy in the healing of chronic anal fissure .  Patients and methods Sixty-four patients with symptomatic chronic anal fissures were r and omly assigned to 0.5 % nifedipine ointment ( n=32 ) every 8 h for 8 weeks or lateral internal sphincterotomy ( n=32 ) . Both groups received stool softeners and fiber supplements and were assessed at 2 , 4 , 6 , and 8 weeks . Long-term outcomes were determined after a median follow-up of 19 months ( nifedipine group ) and 20.5 months ( lateral internal sphincterotomy group ) . Results Complete healing at 8 weeks was achieved in 30 out of 31 patients ( 96.7 % ) in the nifedipine group and 32 out of 32 patients ( 100 % ) in the lateral internal sphincterotomy group ( p=0.49 ) . The overall healing rates at the end of follow-up were 28 out of 30 ( 93 % ) vs. 32 out of 32 ( 100 % ) in the nifedipine and sphincterotomy groups respectively ( p=0.48 ) . Two of the 30 patients in the nifedipine group relapsed whereas none in the sphincterotomy group did . Sixteen patients ( 50 % ) developed side effects in the nifedipine group , compared with six patients ( 18.7 % ) in the sphincterotomy group . Conclusions Topical application of 0.5 % nifedipine ointment represents a new , promising , easily h and led , effective alternative to lateral internal sphincterotomy Several treatments for anal fissure offer different responses and risks for complications . Reversible chemical sphincterotomy with topical nitroglycerin is an alternative to surgical sphincterotomy . The aim of this observational prospect i ve study was to compare the effectiveness of topical nitroglycerin with the conventional medical treatment . Forty-three patients with anal fissure were treated : 22 ( 16 chronic and 6 acute ) received 0.25 % nitroglycerin topically , and 21 ( 16 chronic and 5 acute ) received conventional treatment . Nitroglycerin or placebo was administered in two daily applications for two weeks . Median follow-up was 39 weeks . Healing rate with NTG was 75 % for chronic and 83 % for acute fissures , but recurrence rate for chronic fissures at 9 months was 67 % . Healing rate with placebo for chronic fissures was only anecdotical ( 1 out of 16 patients ) . Headache as side effects occurred in 17 cases ( 77 % ) . In conclusion , both treatments were effective for acute fissures , whereas for chronic ones NTG had a high healing rate but also a high recurrence rate 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 : Chronic anal fissure is a significant cause of morbidity . Internal sphincterotomy has long been the operative treatment of choice . Concerns remain , however , on its effects on continence .  Botulinum toxin has been used as an agent for chemical sphincterotomy , causing temporary alleviation of sphincter spasm and allowing the fissure to heal . The aim of the present study was to compare the results of sphincterotomy to botulinum toxin BACKGROUND Anal fissure is a common disease . Treatment includes conservative measures or surgery . One of the treatment options is topical Nitroglycerin ointment . MATERIAL S AND METHODS We present a prospect i ve , r and omized , double-blind study , encompassing 48 patients suffering from chronic anal fissure . The subjects were divided into three groups according to the dose of Nitroglycerin ointment received -- group I--0 % ( placebo ) , group II--0.2 % ( 0.75 mg ) and group III--0.4 % ( 1.5 mg ) . Demographic data , medical history and physical findings were recorded . Healing , pain relief and adverse events were evaluated during and after the treatment period . RESULTS No significant difference ( p<0.05 ) was found between the groups with respect to patient age , gender , past history , physical examination , amount of ointment used and adverse events .  Thirty three of the 48 ( 69 % ) patients completed the study . No significant differences were found between the groups with respect to the reasons and rates of leaving the study ( p=0.494 ) . Fifteen patients failed to complete the study ; eight patients ( 17 % ) due to headaches  , one patient was operated upon and six patients left the study because of  cooperation problems . No significant difference was found between the groups regarding healing ( p=0.952 ) or pain relief ( p=0.458 - 0.8 according to the type of pain checked ) . CONCLUSIONS According to our study , there was no benefit regarding healing or pain relief , in treating patients suffering from an anal fissure with Nitroglycerin ointment in combination with stool softeners and sitz baths , compared to the same treatment without Nitroglycerin ointment BACKGROUND The aim of this prospect i ve r and omized trial was to compare the effectiveness and morbidity of surgical versus chemical sphincterotomy in the treatment of chronic anal fissure after a 3-year follow-up . METHODS Eighty patients with chronic anal fissure were treated by whether open lateral internal sphincterotomy ( group 1 ) or chemical sphincterotomy with 25 U botulinum toxin injected into the internal sphincter ( group 2 ) . Clinical and manometric results were analyzed . RESULTS Overall healing was 92.5 % in the open sphincterotomy group and 45 % in the toxin botulinum group ( P<.001 ) . There is a group of patients with clinical ( duration of disease > 12 months and presence of a sentinel pile before treatment ) and manometric factors ( persistently elevated mean resting pressure  , % of time presence of slow waves , and  number of patients or the time presence ultra slow waves after treatment ) associated with a higher recurrence of anal fissure . The final percentage of incontinence was 5 % in the open sphincterotomy group and 0 % in the botulinum toxin group ( P>.05 ) . CONCLUSION We recommend surgical sphincterotomy as the first therapeutic approach in patients with clinical and manometric factors of recurrence . We prefer the use of botulinum toxin in patients older than 50 years or with risk factors for incontinence , despite the higher rate of recurrence , since it avoids the greater risk of incontinence in the surgical group 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 Glyceryl trinitrate ( GTN ) ointment ( 0·2 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 BACKGROUND Chronic anal fissure is a frequent and troubling condition , that may need surgical sphincterotomy for relief of symptoms . However , this approach may yield minor incontinence in up to 30 % of cases . Interest has , therefore , recently increased in " chemical sphincterotomy " by using topical glyceryl trinitrate ointment . Unfortunately , there is , to date , no specific pharmaceutical preparation of such compound . AIMS To compare , according to a r and omized double-blind crossover study , the effects of a pharmaceutical preparation of a specific 0.2 % glyceryl trinitrate ointment ( PMF 303 ) and of the common preparation reported in the literature on the anal resting pressure in patients with anal fissure . PATIENTS AND METHODS Twelve patients with chronic anal fissure ( 6 males and 6 females , age range 23 - 60 years ] were recruited for the study . Two paired manometric studies were carried out at one-week intervals . After the basal anal pressure had been assessed , the patients were r and omized to receive either one of the two preparations , and manometric measurements were repeated at 20 , 40 and 60 minutes . RESULTS No differences were found between anal resting pressure in the basal study . Both preparations were able to significantly decrease ( p=0.001 ) anal pressure throughout the study period . No significant differences were found between the two preparations . CONCLUSIONS PMF 303 is able to decrease anal pressure in patients with anal fissure , to a similar extent to the widely tested ( galenic ) literature preparation . Availability of a specific formulation for the treatment of this condition may be clinical ly useful Indoramin is an α1‐adrenoceptor antagonist and has been shown to reduce anal resting pressure . Its therapeutic potential has not been explored . The aim of this study was to determine the outcome of treatment with oral indoramin on patients with chronic anal fissure in the setting of a double‐blind r and omized placebo‐controlled trial Botox ® injection of the anal sphincter muscle cures  chronic uncomplicated anal fissures in up to 80 % of patients . This study examines the therapeutic efficacy and side effect profile of the British botulinum product Dysport ® .  Fifty patients ( 29 women ) were recruited to participate in this r and omized dose‐finding study , their mean age being 32.9 years . The low dose group A was treated with a total dose of 20 U injected in two sites each lateral to the fissure , the high dose group B was treated with 40 U. Eighty‐two percent of patients were pain‐free within a week following the injections . The fissure was healed in 78 % of treated patients after 3 months . Three patients relapsed within 6 months . The most common adverse side effect was transient incontinence ( n = 4 ) . Clinical outcome was not significantly different between the two treatment groups . The low dose can therefore be regarded sufficient for the treatment of anal fissure . Therapeutic efficacy was equivalent to published data on Botox treatment . Both Dysport ® and Botox ® can therefore be used to treat chronic uncomplicated anal fissures . Both Dysport ® and Botox ® therapy are well tolerated , can be performed on an out‐patient basis and avoid the risk of permanent faecal incontinence which complicates surgical treatment of anal fissures Abstract PURPOSE : Nifedipine ( administered orally or applied topically ) has been effective for nonsurgical treatment of anal fissure . We compared the efficacy of nifedipine vs. glyceryl trinitrate for chemical sphincterotomy of anal fissure . METHODS : In a prospect i ve , double-blind trial , 52 patients suffering from chronic anal fissure were r and omly and equally allocated to receive either glyceryl trinitrate or nifedipine , both applied topically to the perianal region . The end point of the study was healing within a predetermined period ( 6 months ) . Variables assessed included demographic data ( age , gender ) , symptoms associated with the fissure , duration of treatment , percentage of healing , untoward effects of treatment , pain scores , duration of follow-up , recurrence , and need for complementary means of treatment . Descriptive data are presented as mean ± st and ard deviation and quantal data as percentage . Inference analysis was performed using the Student ’s t-test for the descriptive data and the chi-squared or Fisher ’s exact test for nominal variables . RESULTS : No significant differences were recorded with regard to age , gender , symptoms associated with the fissure , or duration of treatment . Healing rate was higher ( P < 0.04 ) with nifedipine ( 89 percent ) as compared with glyceryl trinitrate ( 58 percent ) . Treatment side effects ( headache , flushing ) were more frequent ( P < 0.01 ) with glyceryl trinitrate ( 40 percent ) as compared with nifedipine ( 5 percent ) . Pain scores were significantly lower ( P < 0.03 ) on completion of treatment in both groups ( 3.2 in glyceryl trinitrate and 3.4 in nifedipine vs. 6.2 and 6.1 , respectively ) , but did not differ between the two groups . Recurrence occurred in 31 percent of patients treated with glyceryl trinitrate and 42 percent of those treated with nifedipine after a mean period of 18 ± 3 weeks and 12 ± 4 weeks , respectively . CONCLUSION : Topical application of nifedipine for management of chronic anal fissure was more effective and had fewer side effects than topical glyceryl trinitrate . Recurrence was frequent with both drugs PURPOSE As lateral sphincterotomy and anal dilatation causes complications , a reversible chemical sphincterotomy method has been recently proposed as an alternative treatment in patients with anal fissure . In this study , the effect of botulinum toxin causing temporary paralysis in internal anal sphincter was compared with that of lidocaine in patients with chronic anal fissure . METHOD A total of 62 out patients were r and omly assigned to receive botulinum toxin or lidocaine pomade . The patients were evaluated before and after two months of treatment with physical examination and anal manometry . Pain and nocturnal pain were scored . RESULTS In an evaluation period of two months , in 24 of 34 patients of botulinum group ( 70.58 % ) , and in six of 28 patients of lidocaine group ( 21.42 % ) showed complete epithelization ( p = 0.006 ) . All patients who had previously reported nocturnal pain became symptom free in botulinum group and in four patients of lidocaine group . Pain following defecation disappeared in 24 patients of botulinum group and in 20 patients of control group ( p = 0.959 ) . There was no adverse effect in both groups . While resting anal pressure and maximum voluntary pressure were significantly low in botulinum toxin group , both parameters did not change in lidocaine group . CONCLUSIONS Botulinum toxin is a reliable and effective method for patients with chronic anal fissure . It can be applied easily without any anesthesia and instrumentation . It is cheaper in comparison with surgical methods and it can be a good alternative treatment in patients with risk of incontinence INTRODUCTION Topical glyceryl trinitrate ( GTN ) has gained popularity as a treatment for anal fissure in the West . In our country , lignocaine is still the current treatment for the entity . This study was done to compare the effect of GTN with lignocaine in terms of healing rate and recurrence in South Asian population . METHODS A prospect i ve , double blinded , r and omised controlled trial was conducted on 50 patients ( both treatment arms included ) of all ages and either gender with a clinical diagnosis of anal fissure . Group A was given 0.2 % GTN ointment and Group B was given lignocaine ointment . Both subjective and objective signs of healing were assessed and adverse effects of the treatment were sought . RESULTS Symptomatic relief was earlier with GTN as compared with lignocaine .  Pain relief was steady and sustained in those treated with GTN but returned to pre-treatment status within 5 weeks in patients with lignocaine . After 8 weeks of treatment , 80 % of patients in Group A showed clinical signs of healing compared to 32 % in Group B ( p=0.001 ) . Headache was the main side effect of GTN . At 6-month follow-up , recurrence was seen in 3/8 patients in Group B compared to 8/20 in the GTN Group ( p=1 ) . CONCLUSION Topical GTN has earlier and a higher rate of clinical healing of anal fissure with acceptable side effects . The recurrence rate is high and comparable to lignocaine ointment . It is a safe and an effective treatment of anal fissure in a South Asian population Abstract PURPOSE : Chronic anal fissure may be treated by chemical or surgical sphincterotomy . The aim of this study was to test the efficacy of local application of nifedipine and lidocaine ointment in healing  chronic anal fissure .  METHODS : The study was performed according to a prospect i ve , r and omized , double-blind design . One hundred ten patients who gave informed consent were recruited . They received a clinical examination , a question naire to evaluate symptoms and pain , anorectal manometry , and anoscopy . Healing of anal fissure at Day 42 of therapy was defined as the primary efficacy variable of the study . Patients treated with nifedipine ( n = 55 ) used topical 0.3 percent nifedipine and 1.5 percent lidocaine ointment every 12 hours for 6 weeks . The control group ( n = 55 ) received topical 1.5 percent lidocaine and 1 percent hydrocortisone acetate ointment during therapy . Anal pressures were measured by recording resting and maximal voluntary contraction pressures at baseline and at Day 21 . Long-term outcomes were determined after a median follow-up of 18 months . RESULTS : Healing of chronic anal fissure was achieved after 6 weeks of therapy in 94.5 percent of the nifedipine-treated patients ( P < 0.001 ) as opposed to 16.4 percent of the controls . Mean anal resting pressure decreased from a mean value ± st and ard deviation of 47.2 ± 14.6 to 42 ± 12.4 mmHg in the nifedipine group . This represents a mean reduction of 11 percent ( P = 0.002 ) . Changes of maximal voluntary contraction in nifedipine-treated patients were not significant . No changes in mean anal resting pressure and maximal voluntary contraction were observed in the control group . We did not observe any systemic side effect in patients treated with nifedipine . After the blinding was removed , recurrence of the fissure was observed in 3 of 52 patients in the nifedipine group within 1 year of treatment , and 2 of these patients healed with an additional course of topical nifedipine and lidocaine ointment . CONCLUSIONS : Our study clearly demonstrates that the therapeutic use of topical nifedipine and lidocaine ointment should be extended to the conservative treatment of chronic anal fissure Purpose Topical nitroglycerin has been widely used as a means for avoiding surgery in patients with anal fissure . However , nitroglycerin has not been universally accepted for this application because of inconsistency of efficacy and side effects . This study compares conventional digital application with precise intra-anal dosing of nitroglycerin using a specialized dose-delivery device and anal cannula . Methods Twenty-six consecutive patients ( 13 males ) with chronic anal fissure and no previous treatment were r and omly allocated to receive 0.75 ml of 0.3 percent nitroglycerin ointment ( 2.25 mg nitroglycerin ) t.i.d . intra-anal using the cannula ( Group A ) or perianally with the gloved finger ( Group B ) . Nitroglycerin dosage was controlled in Group A by the dose-delivery device connected to the cannula and by single-dose preloaded syringes in Group B. Results Anal manometry : pressure reduction after application of nitroglycerin was 47 ± 18.6 in Group A and 20.7 ± 13.4 percent in Group B ( P < 0.01 ) . Headaches were reported by 1 of 10 patients in Group A and 10 of 12 patients in Group B ( P = 0.0027 ) . Seven patients of Group B had to be crossed to intra-anal treatment as a result of intensity of headaches . Pain relief was noted by 8 of 10 and 9 of 12 patients in Groups A and B , respectively ( P = 0.6 ) . Sphincterotomy was required in only 13.6 percent of all patients . Conclusions Controlled intra-anal dosing of topical nitroglycerin produces a significantly greater reduction in sphincteric pressure and lower incidence of headaches than with perianal administration of the same dose ofointment . These results suggest a new paradigm for increasing safety and efficacy of dose-dependent prescription anal topical medications Objective R and omized 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 aim ed to evaluate the efficacy of  topical GTN  for anal fissures in an outpatient setting Purpose : The aim of this trial was to compare lateral internal sphincterotomy with local 0.2 percent isosorbide dinitrate in the treatment of chronic anal fissure to minimize surgical complications such as minor fecal incontinence . Methods : Fifty-four patients with chronic anal fissure were r and omized in a prospect i ve trial to either sphincterotomy or local 0.2 percent isosorbide dinitrate . All patients had anal function tests before and 5 weeks after treatment . Results : In the ointment group , 18 patients ( 67 percent ) healed at 5 weeks and 24 ( 89 percent ) healed at 10 weeks of treatment . Maximum resting anal pressure was reduced 30 percent . Eight patients ( 30 percent ) had minor side effects . In the surgical group , 26 patients ( 96 percent ) healed at 5 weeks and 100 percent healed at 10 weeks after treatment , with 33 percent reduction in maximum resting anal pressure . Forty-four percent of patients had minor fecal incontinence , which remained in 15 percent after 24 months follow-up . No statistical difference in maximum resting anal pressure was found between groups ( P = 0.16 ) , but the percentage of healing at 5 weeks was greater in the surgical group ( P < 0.001 ) . Conclusions : Isosorbide dinitrate ointment must be considered as the first choice of treatment in patients with chronic anal fissure . Surgery should be indicated if chemical sphincterotomy fails INTRODUCTION The duration of physiologic action of topical glyceryl trinitrate in the management of anal fissure has been the source of some controversy . This study was design ed to assess the manometric effect of glyceryl trinitrate on internal sphincter resting tone with continuous monitoring . METHODS Twenty-seven patients with a chronic anal fissure were assessed with fissure , pain , bleeding , and continence scores .  Twenty-two were r and omized to 1 cm of topical 0.2 percent glyceryl trinitrate paste , applied to the lower anal canal . Five patients were r and omized to 1 cm of water-soluble lubricating jelly to the lower anal canal . Continuous stationary six radial channel water perfusion anorectal manometry was performed for 5 minutes before treatment and then for a further 30 minutes . The 22 glyceryl trinitrate patients were then advised to apply topical 0.2 percent glyceryl trinitrate , three times daily , for eight weeks . Twenty-four hours after completing treatment , all baseline assessment s were repeated . The lubricant jelly cohort was discharged from the study after the initial assessment . RESULTS During the initial manometric assessment , 21 glyceryl trinitrate patients ( 95 percent ) had 20 percent or more reduction in mean and maximum anal resting pressure after treatment . However , there was no statistical difference at 20 minutes compared with 0 minutes ( P > 0.1 ) . After eight-week treatment , 16 patients ( 73 percent ) reported symptom resolution and 15 ( 67 percent ) were found to be healed on examination . Clinical healing and resolution of symptoms positively correlated with a higher pretreatment maximum anal resting pressure in the mid anal canal ( P < 0.0001 ) , lower fissure score ( P < 0.0001 ) , and greater percentage reduction of the maximum resting pressure after application of glyceryl trinitrate ( P < 0.001 ) . The mean and maximum anal resting pressure at Week 8 was not significantly different from the baseline values ( P > 0.05 ) . During continuous manometry , the anal resting pressure did not significantly change in the patients treated with lubricating jelly . CONCLUSIONS In those patients with a lower fissure score , a higher mid anal canal anal resting pressure , and a greater resting pressure reduction after glyceryl trinitrate application , a favorable clinical outcome can be expected with glyceryl trinitrate treatment . However , because the physiologic response has resolved in fewer than 20 minutes , the dosing regime should be reassessed BACKGROUND AND METHODS Lateral internal sphincterotomy , the most common treatment for chronic anal fissure , may cause permanent injury to the anal sphincter , which can lead to fecal incontinence . We compared two nonsurgical treatments that avert the risk of fecal incontinence . We r and omly assigned 50 adults with symptomatic chronic posterior anal fissures to receive treatment with either a total of 20 U of botulinum toxin injected into the internal anal sphincter on each side of the anterior midline or 0.2 percent nitroglycerin ointment applied twice daily for six weeks . RESULTS After two months , the fissures were healed in 24 of the 25 patients ( 96 percent ) in the botulinum-toxin group and in 15 of the 25 ( 60 percent ) in the nitroglycerin group ( P=0.005 ) . No patient in either group had fecal incontinence . At some time during treatment , five patients in the nitroglycerin group had transient , moderate-to-severe headaches that were related to treatment . None of the patients in the botulinum-toxin group reported adverse effects . Ten patients who did not have a response to the assigned treatment - 1 in the botulinum-toxin group and 9 in the nitroglycerin group - crossed over to the other treatment ; the fissures subsequently healed in all 10 patients . There were no relapses during an average of about 15 months of follow-up . CONCLUSIONS Although treatment with either topical nitroglycerin or botulinum toxin is effective as an alternative to surgery for patients with chronic anal fissure , botulinum toxin is the more effective nonsurgical treatment PURPOSE : 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 prospect i ve , r and omized 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 ) ) . DISCUSSION : 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 h and led , 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 PURPOSE : This study was performed according to a prospect i ve , r and omized , double-blind , multicenter design . The aim was to test the efficacy of local application of nifedipine gela in healing acute anal fissure  by relaxing the internal anal sphincter . METHODS : Two hundred eighty-three patients who gave informed consent were recruited ; they received a clinical examination . A question naire to evaluate the symptoms and the pain was administered , and a proctoscopy and anorectal manometry were performed . Patients treated with nifedipine ( n=141 ) used topical 0.2 percent nifedipine gel every 12 hours for three weeks . The control group , consisting of 142 patients , received topical 1 percent lidocaine and 1 percent hydrocortisone acetate gel during therapy . Manometry was performed before and on Days 14 and 21 . Anal pressures were measured by recording resting and squeeze pressures . RESULTS : Results obtained were as follows : total remission from acute anal fissure was achieved after 21 days of therapy in 95 percent of the nifedipine-treated patients ( P<0.01 ) , as opposed to 50 percent of the controls ( P<0.01 ) , and previously elevated maximum resting anal pressures decreased from a mean value ± st and ard deviation of 72.5±10.07 mmHg to 50.5±10.03 mmHg in the nifedipine group . This represents a mean reduction of 30 percent ( P<0.01 ) . We also observed a significant decrease in squeeze pressures in nifedipine-treated patients ( from a mean ± st and ard deviation of 130.5±19.25 mmHg to 108.5±18.55 mmHg , a mean reduction of 16.8 percent;P<0.01 ) . No changes in anal pressures were observed in the control group . We did not observe any systemic side effect or significant anorectal bleeding in patients treated with nifedipine . CONCLUSIONS : Our study clearly demonstrates that the therapeutic use of nifedipine , which at present is used only in cardiovascular pathologies , should be extended with local use to the conservative treatment of anal fissures PURPOSE : Internal anal sphincterotomy for treating chronic anal fissure can irreversibly damage anal continence . Reversible chemical sphincterotomy may be achieved by anal application of glyceryl trinitrate ointment ( nitric oxide donor ) , which has been reported to heal the majority of patients with anal fissure by inducing sphincter relaxation and improving anodermal blood flow . This trial aim ed to further clarify the role of glyceryl trinitrate in the treatment of chronic anal fissure . METHODS : A total of 132 consecutive patients from nine centers were r and omly assigned to receive 0.2 percent glyceryl trinitrate ointment or placebo twice daily for at least four weeks . The severity of pain and maximum anal resting pressure were measured before and after one week of treatment . Anodermal blood flow was measured before and after application of glyceryl trinitrate or placebo in ten patients . RESULTS : The study was completed by 119 patients ( 59 glyceryl trinitrate and 60 placebo ) , matched for gender , age , duration of symptoms , duration of treatment , site of fissure , previous attempts to treat , pain score , and maximum anal resting pressure . Twenty-nine patients ( 49.2 percent ) healed after glyceryl trinitrate and 31 patients ( 51.7 percent ) healed after placebo ( P= not significant ) . Pain score fell significantly in both groups , in addition to maximum anal resting pressure . Anodermal blood flow improved significantly in seven patients receiving glyceryl trinitrate , but not in the three receiving placebo . Twenty-three patients ( 33.8 percent ) experienced headache and 4 ( 5.9 percent ) , orthostatic hypotension after glyceryl trinitrate . CONCLUSION : This trial fails to demonstrate any superiority of topical 0.2 percent glyceryl trinitrate treatmentvs . a placebo , although the effects of glyceryl trinitrate on anodermal blood flow and sphincter pressure are confirmed . This finding , together with the high incidence of side-effects , should discourage the use of this treatment as a substitute for surgery in chronic anal fissure BACKGROUND Botulinum toxin induces healing in patients with idiopathic anal fissures . METHODS One hundred-fifty patients with posterior anal fissures were treated with botulinum toxin injected in the internal anal sphincter on each side of the anterior midline . Subjects were r and omized into 2 treatment groups based on the number of units of botulinum toxin injected . Patients in group I were treated with 20 units of botulinum toxin and , if the fissure persisted , were retreated with 30 units . Patients in group II were treated with 30 units and retreated with 50 units , if the fissure persisted . RESULTS The 2 groups were comparable in age , gender distribution , duration of symptoms , resting pressure , and maximum voluntary pressure at anorectal manometry . One month after the injection , examinations revealed complete healing in 55 patients ( 73 % ) from group I and 65 patients ( 87 % ) from group II ( P = .04 ) . Five patients from group II reported a mild incontinence of flatus that lasted 2 weeks after the treatment and disappeared spontaneously . The values of the resting anal pressure ( P=.3 ) and the maximum voluntary pressure ( P = .2 ) did not differ between the 2 groups . At 2 months ' evaluation , a healing scar was found in 67 patients ( 89 % ) from group I and 72 patients ( 96 % ) from group II . A relapse of the fissure was observed in 6 patients ( 8 % ) from group I who had a healing scar at 1 month , and 2 other patients never healed . A persistent fissure was present in 3 patients from group II who had no other symptoms . CONCLUSIONS Botulinum toxin injected into the internal anal sphincter is effective in managing anal fissures and avoiding permanent complications . All patients were treated with the active drug and healed after 1 or 2 successive treatments . The results also confirm that higher doses account for a higher success rate , with little increase in complications or side effects , which is probably related to the diffusion of the toxin to the external sphincter BACKGROUND 0.2 per cent topical glyceryl trinitrate ( GTN ) ointment heals up to two-thirds of  chronic anal fissures in adults although many patients experience troublesome headaches . This double blind r and omised pilot study assessed the efficacy and side effects of 0.1 and 0.05 per cent GTN ointment in treatment of chronic anal fissures in children . MATERIAL / METHODS 15 consecutive children with chronic anal fissures were r and omised to receive either 0.05 or 0.1 per cent GTN ointment applied topically twice daily for eight weeks . Clinical review was undertaken at weeks 4 and 8 and questions relating to symptoms and the incidence of headache were asked . RESULTS The median age of the 15 ( 8 male ) patients was 6 years ( range 3 - 13 ) . There were 5 anterior and 10 posterior fissures . The median duration of symptoms was 9 ( 3 - 30 ) months . 13/15 ( 86.7 % ) patients were taking laxatives at the time of referral . Fissure healing was complete at 8 weeks in all seven patients who received 0.05 % and in 5/8 ( 62.5 % ) patients using the 0.1 % ointment ( Fisher 's exact test , not significant ) . One patient from each arm experienced headaches during the first week of the trial which resolved without treatment and did not affect compliance . There were no other side effects . CONCLUSIONS Topical glyceryl trinitrate ointment is effective in healing chronic anal fissures in children .  Healing rates and side effect profile are comparable when either 0.05 or 0.1 per cent ointment is used OBJECTIVE To compare symptomatic relief , healing , and changes in maximal anal resting pressure with the use of topical formulations in patients with chronic anal fissure . METHODS Sixty-four consecutive patients with chronic anal fissure were r and omized into 4 groups that received , in a double-blind manner , a topical ointment that contained 0.2 % nitroglycerine ( GTN ) , 5 % xylocaine , Proctosedyl ( hydrocortisone acetate , heparin , framycetin sulfate , esculoside , ethoform , butoform ) or petroleum jelly ( Vaseline ) , to be applied twice daily . Patients were review ed at 2-week intervals for 6 weeks . Anal manometry was done before , and 20 minutes after , the first application of the ointment . RESULTS There was significant ( p < 0.0001 ) reduction in mean anal resting pressure after application of GTN , but not any other ointment . Of 16 patients receiving GTN , complete pain relief occurred in 6 and 15 patients after 2 and 4 weeks of treatment , respectively ; this was more frequent than in the other 3 groups . At 6 weeks also , complete pain relief occurred more often with GTN than with Vaseline or xylocaine . After 4 weeks of treatment , 3 patients on GTN had complete healing of fissure as compared to one each in the xylocaine and Proctosedyl groups and none in the Vaseline group . At 6 weeks , healing of fissure had occurred in 15 of 16 patients receiving GTN as compared to 4 receiving Vaseline , 11 receiving xylocaine , and 12 on Proctosedyl . CONCLUSIONS Topical nitroglycerine produces ' chemical sphincterotomy ' with reduction in mean anal resting pressure . Pain relief and healing of fissure occurred earlier with GTN than with other treatments . GTN should be considered as the treatment of choice for the non-surgical management of patients with chronic anal fissure OBJECTIVE To compare outcomes 24 months after treatment of chronic anal fissure with 0.2 % glyceryl trinitrate ointment ( GTN ) or lateral internal sphincterotomy .  DESIGN Prospect i ve , r and omised trial . SETTING One teaching , one private , and 3 district hospitals , U.K. SUBJECTS Seventy patients were r and omised 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 r and omised 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 BACKGROUND Topical glyceryl trinitrate ( GTN ) may produce healing of anal fissure by decreasing the high resting anal sphincter pressure in these patients . The present study assessed the efficacy of GTN in chronic anal fissure in a double-blind placebo-controlled trial . METHOD Patients with chronic anal fissure ( for more than 8 weeks ) underwent measurement of maximum anal resting pressure ( MARP ) before and 12 minutes after application of either 0.2 % GTN or placebo ointment in a r and omized manner . They then received twice-daily local application of their respective ointment for 6 weeks . Symptoms and healing of fissure were assessed ; patients were evaluated at 3 months for evidence of relapse . RESULTS 19 adult patients ( 12 men ) were studied ; 10 received GTN and 9 placebo .  Mean ( SD ) MARP decreased from 131.0 ( 32.3 ) cm H2O to 93.5 ( 28.4 ) cm H2O ( p<0.05 ) with GTN and from 150.5 ( 36.9 ) cm H2O to 142.8 ( 35.0 ) cm H2O ( p = ns ) with placebo .  Fissure healed in 7 of 10 patients treated with GTN and 2 of 9 patients treated with placebo ( p<0.05 ) . There was no relapse of fissure in either group . CONCLUSION Local application of GTN was effective in healing chronic 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 r and omly 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 review ed , 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 Background and aim : Hypertonicity of internal anal sphincter plays a major role in the persistence of chronic anal fissure .  Botulinum toxin could induce internal anal sphincter relaxation without the adverse effects of surgery ( long‐term faecal incontinence ) or topical nitrates  ( anal burning , headaches , hypotension ) AIM Anal fissures are associated with hypertonia of the internal anal sphincter and pain . We evaluated the efficacy of local application of a combination of minoxidil and lignocaine in healing anal fissures . METHODS In this prospect i ve , r and omized , double-blind study , 90 patients with anal fissure were recruited . Patients received local applications of ointments containing 5 % lignocaine ( n=28 ) , 0.5 % minoxidil ( n=36 ) , or both ( n=26 ) . Healing of anal fissure at 6 weeks was used as the primary end-point . RESULTS Rates of complete healing of fissure were similar in the three groups ( lignocaine alone 8/27 , minoxidil alone 10/34 , combination 7/22 ; p = ns ) . Mean ( SD ) time taken for complete healing with combination treatment [ 1.9 ( 0.6 ) weeks ] was significantly shorter than that with minoxidil alone ( 3.1 [ 1.7 ] weeks ; p=0.001 ) or with lignocaine alone ( 3.3 [ 0.8 ] weeks ; p=0.002 ) . Rates of pain relief were similar in the three groups . Stoppage of bleeding occurred more often with combination treatment than with lignocaine alone . No patient had systemic or local side effects . CONCLUSION Combination treatment with minoxidil and lignocaine helps in faster healing of anal fissures and provides better symptomatic relief than either drug alone Patients presenting with acute anal fissure were r and omized into two treatment groups in a prospect i ve clinical trial . Both groups received treatment for 3 weeks with a stool softener and lignocaine jelly . Those entered in group 1 ( 35 patients ) were asked in addition to insert an anal dilator ( no. 2 ) twice daily while those in group 2 ( 31 patients ) applied the anaesthetic jelly without a dilator . At 6 weeks 11 ( 31·4 per cent ) patients in group 1 and 12 ( 38·7 per cent ) patients in group 2 had been referred for sphincterotomy owing to failure of the treatment . At 6 months this figure had risen to 14 ( 40 per cent ) in group 1 and 15 ( 48·4 per cent ) in group 2 . This difference was not statistically significant , suggesting that the addition of a dilator to the conservative treatment regimen did not diminish the likelihood of surgery PURPOSE : A r and omized , double-blind , placebo-controlled trial was performed to test the effect of intra-anal glyceryl trinitrate ointment in patients with chronic anal fissures that would normally have been treated by sphincterotomy . Long-term follow-up was then performed to assess fissure healing . METHODS : Patients with chronic anal fissures were r and omly assigned to 0.2 percent topical glyceryl trinitrate ointment or placebo . Anal manometry was performed before treatment , one week later , and 48 hours after treatment ceased at four weeks . Fissure healing was assessed by an observer blinded to the treatment arm . Pain was recorded on a linear analog scale . At the completion of the trial , treatment was continued with glyceryl trinitrate until fissure healing was obtained or lateral sphincterotomy was performed if required for ongoing pain . A long-term follow-up assessment was made at a mean of 29 ( range , 25–33 ) months . RESULTS : There was a significant reduction in anal resting pressure at Week 1 with glyceryl trinitrate ( P=0.001 ) but not placebo , and at Week 4 there was a significant reduction in pain score with glyceryl trinitrate ( P=0.001 ) and placebo ( P=0.01 ) and a significant reduction in fissure grade with glyceryl trinitrate ( P=0.0001 ) and placebo ( P=0.02 ) . Forty-six percent of fissures healed with glyceryl trinitrate and 16 percent healed with placebo ( P=0.001 ) . At long-term follow-up in 40 of 43 patients , 14 patients ( 35 percent ) had undergone lateral sphincterotomy , and in the remainder who were treated with glyceryl trinitrate there was a significant reduction in pain score ( P=0.0002 ) . Seventeen patients attended for repeat manometry and fissures were healed with glyceryl trinitrate in ten ( 59 percent ) cases . High internal sphincter pressures persisted at long-term follow-up in patients successfully treated with glyceryl trinitrate , indicating that the sphincter is the cause rather than effect of anal fissure . CONCLUSION : Topical glyceryl trinitrate produces a successful internal sphincterotomy , which result ed in long-term healing of 59 percent of chronic anal fissures and significant improvement in pain . Internal sphincter spasm is the cause of chronic anal fissure Purpose This study was design ed to assess the safety and efficacy of 0.2 percent glyceryl trinitrate suppository form in the healing of  chronic anal fissure .  Methods Thirty-four patients with symptomatic chronic anal fissures were assigned to 0.2 percent glyceryl trinitrate suppository ( n = 21 ) or placebo ( n = 13 ) in a double blind design . Patient 's symptom scores were registered at first visit . A vali date d daily chart was given to assess their symptoms on a daily basis . Both groups received psyllium from the beginning of the study . They were assessed at two-week intervals for six weeks . Then , they started a washout period of one month and after that were crossed over for another six weeks . Chi-squared , t-tests , and analysis of variance were used for statistical analysis . Results Complete healing at six weeks was achieved in 12 of 21 patients ( 57 percent ) in the glyceryl trinitrate group and 5 of 13 patients ( 38 percent ) in the placebo ( P < 0.05).The overall healing rates at the end of study were 15 of 21 ( 71 percent ) vs. 11 of 13 ( 84 percent ) in the glyceryl trinitrate and placebo groups , respectively ( P > 0.05 ) . Conclusions Application of 0.2 percent glyceryl trinitrate suppository form represents a new , promising , and effective treatment for chronic anal fissure Procedures involving the use of anal dilators or topical nitroderivatives for the treatment of anal fissure are efficacious , economic and safe . The aim of our study was to compare the efficacy of two conservative treatments - passive dilation with anal dilators or topical nitroderivatives - in reducing anal pressure and resolving anal fissures . A total of 40 patients with a clinical diagnosis of acute anal fissure in the absence of hypotonic anal sphincter , abscess or perianal fistula , haemorrhoidal thrombosis , chronic inflammatory bowel disease or lower gastrointestinal neoplasia were r and omly assigned to treatment with dilators ( 20 patients ) or topical nitroderivatives ( 20 patients ) . After 4 weeks of treatment , 90 % of patients treated with dilators and only 45 % treated with topical nitroderivatives showed complete resolution of their anal fissures and a reduction of sphincter hypertone . After 12 weeks , 2/18 patients successfully treated with dilators and 1/9 patients successfully treated with topical derivatives presented recurrence of the anal fissure . The use of anal dilators would appear to induce better resolution of acute anal fissures than topical nitroderivates , as confirmed by the low relapse rate at 12 weeks Background : Botulinum neurotoxin induces healing in patients with idiopathic fissure . The optimal dosage is not well established Abstract PURPOSE : Botulinum toxin injection into the internal anal sphincter has been shown to be an effective treatment for chronic anal fissure . A r and omized , prospect i ve trial was conducted to compare botulinum toxin with lateral internal anal sphincterotomy as definitive management for chronic anal fissure . METHODS : Patients diagnosed as having chronic anal fissure were r and omly assigned to one of the two treatment arms . In the botulinum toxin  group ( n = 61 ) , 20 to 30 U ( approximately 0.3 U/kg ) of type A botulinum toxin ( Botox ® ) was injected into the internal anal sphincter . The injection was repeated two months later if complete healing was not accomplished . Patients in the sphincterotomy group ( n = 50 ) underwent lateral internal anal sphincterotomy . The same investigators evaluated the patients on postoperative/postinjection days 7 and 28 , and then in a blinded manner at 2 , 6 , and 12 months . RESULTS : In the botulinum group , single injection result ed in complete healing in 45 of the 61 patients ( 73.8 percent ) at the second month . Of the 16 failures , 6 patients refused further treatment , and 10 were treated with a second injection , which result ed in an overall healing rate of 86.9 percent ( 53/61 ) at 6 months . In the sphincterotomy group , the success rate was 82 percent ( 41/50 ) at day 28 and 98 percent ( 49/50 ) at the second month ( P = 0.023 and P < 0.0001 , respectively , compared with the botulinum group — single injection ) . At 6 months , 2 patients in the LIS group developed recurrences , and the healing rate was similar to that of the botulinum group ( 86.9 vs. 96.4 percent ; P = 0.212 ) . At 12 months , the success rate of the Botox ® group fell to 75.4 percent ( 46/61 ) with 7 recurrences , whereas it remained stable in the sphincterotomy group ( 94 percent , P = 0.008 ) . Sphincterotomy was associated with a significantly higher complication rate ( 8 cases of anal incontinence vs. none in the botulinum toxin group ; P < 0.001 ) . Full return to daily activities took significantly less time in the botulinum group ( 1 vs. 14.8 ± 5.7 days ; P < 0.0001 ) . CONCLUSION : Although the healing rate of chronic anal fissure is considerably high with botulinum toxin injection with earlier recovery and less complications compared with sphincterotomy , it occasionally requires a repeat injection , and the healing is slower . The early ( two months ) and late ( one year ) healing rates are significantly higher in the sphincterotomy group , the two groups reaching similar healing rates only at six months INTRODUCTION : Chemical sphincterotomy has proved effective in treating chronic anal fissure .  Glyceryl trinitrate is the most widely used agent , and topical 0.2 percent glyceryl trinitrate ointment heals up to two thirds of chronic anal fissures . Unfortunately , however , many patients experience troublesome headaches as a side effect of this treatment . This study assessed the effectiveness of oral and topical diltiazem in healing chronic fissures . METHODS : Fifty consecutive patients with chronic anal fissures were r and omly assigned to receive oral ( 60 mg ) or topical ( 2 percent gel ) diltiazem twice daily for up to eight weeks . Anal manometry was performed before and after the first dose , and blood pressure was recorded at 15-minute intervals . Patients were review ed fortnightly , pain was expressed with a visual linear analog scale , blood pressure was recorded , fissure healing was assessed , and side effects were noted . RESULTS : Twenty-four patients received oral diltiazem , and 26 received topical diltiazem . Mean ( ± st and ard error of the mean ) maximum resting anal pressures fell by 15 and 23 percent from 95±4 to 81±4 and from 102±5 to 79±5 cm H2O in the two groups , respectively . There was no significant reduction in blood pressure during the study or at follow-up in either group . Fissure healing was complete in 9 patients ( 38 percent ) receiving oral diltiazem and 15 ( 65 percent ) on topical treatment by eight weeks . Oral diltiazem caused side effects in eight patients ( rash , two ; headaches , two ; nausea or vomiting , three ; reduced smell and taste , one ) , whereas no side effects were seen in those receiving topical therapy ( P=0.001 ) . CONCLUSION : Oral and topical diltiazem heal chronic anal fissures . Topical diltiazem is more effective , achieving healing rates comparable to those reported with topical nitrates , with significantly fewer side effects BACKGROUND / PURPOSE Anal fissures would result in constipation in children , worsening the clinical picture , thus , justifying a fast response therapy . In this r and omized , prospect i ve , placebo-controlled study , it was aim ed to determine the response rates to fissure treatment by lidocaine , EMLA and GTN on the 10th day and after 8 weeks of therapy . Related childhood literature is scarce , and EMLA is tried for the first time in fissure treatment . METHODS One hundred two children with anal fissures were allocated r and omly into 4 groups . Placebo group ( P ; n = 20 ) received vaseline ; group L ( n = 24 ) , 10 % lidocaine ; group EMLA ( n = 25 ) , eutectic mixture of 5 % prilocaine-5 % lidocaine ; and group GTN ( n = 22 ) , 0.2 % glyceryl trinitrate ointment twice daily to the distal anal canal . Symptoms and physical findings were separately scored as 0 , 1 , and 2 . On the 10th day , the number of patients with scores of 0 ( unresponsive ) and in the 8th week with scores of 2 ( healed and symptom free ) were analyzed statistically . RESULTS Ninety-one patients completed the study . On the 10th day children with 0 symptomatic and fissure healing scores were , respectively , 90 % to 95 % in group P , 75 % to 80 % in group L , 20 % to 40 % in group EMLA , and 5 % to 10 % in group GTN . These results were statistically significant . In the eighth week , children with symptomatic and healing scores of 2 were , respectively , 10 % to 5 % in group P , 42 % to 29 % in group L , 76 % to 64 % in group EMLA , and 91 % to 82 % in group GTN . Results in groups GTN and EMLA were statistically similar ( P > .05 ) and better than the other 2 groups ( P < .05 ) . CONCLUSION Faster response rates could be achieved by GTN application , and similar and high success rates could be gained by GTN or EMLA by 8 weeks of treatment 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 Lateral internal sphincterotomy has been the st and ard treatment for chronic anal fissure , but fissure healing rates of up to 80 % with topical glyceryl trinitrate ( GTN ) treatment have suggested that this operation may become redundant . We evaluated the results of topical treatment of chronic anal fissures with 0.2 % GTN for 6 weeks in the outpatient clinical setting , outside the confines of a r and omized clinical trial . The role of lateral internal sphincterotomy in the GTN era was also assessed . GTN induced fissure healing in 21 of 49 consecutive patients .  Fissures healed spontaneously in 2 patients who discontinued GTN because of headache . Lateral internal sphincterotomy was performed in 26 patients who had persistent symptoms after 6 weeks of GTN therapy . At the 6-week post-sphincterotomy review , all fissures had healed and there were no complications . In this study topical GTN for treatment of chronic anal fissure in the outpatient setting was not as effective as demonstrated in controlled clinical trials . Lateral internal sphincterotomy is still a good therapeutic option , especially in patients not responding to GTN PURPOSE : This study was undertaken to compare local application of a glyceryl trinitrate ointment with lateral internal sphincterotomy for the treatment of chronic fissure-in-ano . PATIENTS AND METHODS : A sample of 24 consecutive patients with chronic anal fissure was r and omly allocated to treatment with sphincterotomy or local glyceryl trinitrate . Patients were followed-up for a median of 22 months . RESULTS : All 12 patients healed following sphincterotomy ; 10 of 12 healed with local glyceryl trinitrate ( P=0.239 ) . There were no recurrences or side-effects in either group . CONCLUSIONS : Local application of glyceryl trinitrate can avoid surgery in more than 80 percent of patients with chronic anal fissure OBJECTIVE To assess the efficacy of isosorbide dinitrate in healing anal fissures . DESIGN R and omised , prospect i ve , double blind , placebo controlled trial . SETTING Teaching hospital , The Netherl and s. SUBJECTS 37 consecutive subjects with anal fissure diagnosed in the surgical outpatient department . INTERVENTIONS After r and omisation , 20 patients were given isosorbide dinitrate , and 17 patients placebo . MAIN OUTCOME MEASURES Healing of anal fissure , recurrence , and tolerance . RESULTS Both groups were treated for a median ( range ) of 5 weeks ( range 1 - 10 ) . After this period , 17 in the isosorbide group had healed compared with 6 controls ( p < 0.003 ) . The fissure recurred in 2 patients who had had an initial good response to isosorbide , and in 2 in the control group . Side effects ( particularly headache ) were more common after isosorbide dinitrate , but not significantly so ( 9/20 compared with 3/17 ) . CONCLUSIONS Isosorbide dinitrate is an effective treatment for anal fissure , and is significantly better than placebo BACKGROUND Botulinum toxin induces healing in patients with idiopathic anal fissure . METHODS Fifty patients affected by posterior anal fissure were treated with 20 units of botulinum toxin , injection in the internal anal sphincter on each side of the posterior midline ( group I ) or on each side of the anterior midline ( group II ) . RESULTS At 2 months evaluation , a healing scar was observed in 15 patients of group I and in 22 patients of group II(P = 0.025 ) . Resting anal pressure was significantly different from the baseline values at 1-month as well as at 2-month check-ups in both groups , but the values were significantly lower in patients of group II . CONCLUSIONS The intersite comparison revealed that anterior injection of the internal anal sphincter result ed in improved lowering of resting anal pressure and produced an earlier healing scar Purpose This study was design ed to assess whether addition of glyceryl trinitrate to botulinum toxin improves the healing rate of glyceryl trinitrate-resistant fissures over that achieved with botulinum toxin alone . Methods Patients were r and omized between botulinum toxin plus glyceryl trinitrate ( Group A ) and botulinum toxin plus placebo paste ( Group B ) . Patients were seen at baseline , four and eight weeks , and six months . The primary end point was fissure healing at eight weeks . Secondary end points were symptomatic relief , need for surgery , side effects , and reduction in maximum resting and squeeze pressures . Results Thirty patients were r and omized . Two-thirds of patients had maximum anal resting pressures below or within the normal range at entry to the study . Healing rates in both treatment groups were disappointing . There was a nonsignificant trend to better outcomes in Group A compared with Group B in terms of fissure healing ( 47 vs. 27 percent ) , symptomatic improvement ( 87 vs. 67 percent ) , and resort to surgery ( 27 vs. 47 percent ) . Conclusions There is some evidence to suggest that combining glyceryl trinitrate with botulinum toxin is superior to the use of botulinum toxin alone for glyceryl trinitrate-resistant anal fissure . The poor healing rate may reflect the fact that many of the patients did not have significant anal spasm at trial entry
target: 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: 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 .