Lateral sphincterotomy compared with anal advancement flap for chronic anal fissure The effect of topical nifedipine in treatment of chronic anal fissure. A Study of Fecal Incontinence in Patients with Chronic Anal Fissure: Prospective, Randomized, Controlled Trial of the Extent of Internal Anal Sphincter Division During Lateral Sphincterotomy A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. Comparative Study of Glyceryl Trinitrate Ointment Versus Surgical Management of Chronic Anal Fissure Botulinum toxin injection versus lateral internal sphincterotomy for the treatment of chronic anal fissure: randomized prospective controlled trial Lack of effficacy of botulinum toxin in 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 Long-term results of topical nitroglycerin in the treatment of chronic anal fissures are disappointing Faecal incontinence in patients with anal fissure: a consequence of internal sphincterotomy or a feature of the condition? [Mucosa advancement flap anoplasty in treatment of chronic anal fissures: a prospective, multicenter, randomized controlled trial]. Chronic anal fissures treated with botulinum toxin injections: a dose‐finding study with Dysport® Glyceryl trinitrate for chronic anal fissure—Healing or headache? A randomized trial of glyceryl trinitrate ointment and nitroglycerin patch in healing of anal fissures Anterior Levatorplasty for the Treatment of Chronic Anal Fissures in Females With a Rectocele: A Randomized, Controlled Trial Topical diltiazem vs. topical glyceril trinitrate in the treatment of chronic anal fissure: a prospective, randomized, double-blind trial. A prospective, randomized, double-blind, placebo-controlled trial of glyceryl-trinitrate ointment in the treatment of children with anal fissure. Pneumatic Balloon Dilatation for Chronic Anal Fissure: A Prospective, Clinical, Endosonographic, and Manometric Study Internal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure Randomised Prospective Controlled Trial of Topical 2 % Diltiazem Versus Lateral Internal Sphincterotomy for the Treatment of Chronic Fissure in Ano Topical diltiazem hydrochloride and glyceryl trinitrate in the treatment of chronic anal fissure. Randomized, prospective trial comparing 0.2 percent isosorbide dinitrate ointment with sphincterotomy in treatment of chronic anal fissure: A two-year follow-up Clinical, Manometric, and Ultrasonographic Results of Pneumatic Balloon Dilatation vs. Lateral Internal Sphincterotomy for Chronic Anal Fissure: A Prospective, Randomized, Controlled Trial Botulinum Toxin Injection Versus Lateral Internal Sphincterotomy in the Treatment of Chronic Anal Fissure: A Randomized Controlled Trial Comparison of Glycerine Trinitrate and Botulinum Toxin-A for the Treatment of Chronic Anal Fissure: Long-Term Results Randomized Clinical Trial of Botulinum Toxin Plus Glyceryl Trinitrate vs. Botulinum Toxin Alone for Medically Resistant Chronic Anal Fissure: Overall Poor Healing Rates Local nitroglycerin for treatment of anal fissures: An alternative to lateral sphincterotomy? Anal dilatation versus left lateral sphincterotomy for chronic anal fissure: a prospective randomized study Botulinum toxin versus botulinum toxin with low-dose glyceryltrinitrate for healing of chronic anal fissure: a prospective, randomised trial. Incontinence After Lateral Internal Sphincterotomy: A Prospective Study and Quality of Life Assessment Lateral internal sphincterotomy versus 0.25 % isosorbide dinitrate ointment for chronic anal fissures: a prospective randomized controlled trial Comparative study of lateral internal sphincterotomy versus local 0.2% glyceryl trinitrate ointment for the treatment of chronic anal fissure. A randomized trial of botulinum toxin vs lidocain pomade for chronic anal fissure. A dose finding study with 0.1%, 0.2%, and 0.4% glyceryl trinitrate ointment in patients with chronic anal fissures Comparative Study of Conventional Lateral Internal Sphincterotomy, V-Y Anoplasty, and Tailored Lateral Internal Sphincterotomy with V-Y Anoplasty in the Treatment of Chronic Anal Fissure Partial Lateral Internal Sphincterotomy versus Combined Botulinum Toxin A Injection and Topical Diltiazem in the Treatment of Chronic Anal Fissure: A Randomized Clinical Trial A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure Glyceryl trinitrate vs. lateral sphincterotomy for chronic anal fissure: Prospective, randomized trial Comparison of controlled-intermittent anal dilatation and lateral internal sphincterotomy in the treatment of chronic anal fissures: a prospective, randomized study. Surgical versus chemical (botulinum toxin) sphincterotomy for chronic anal fissure: long-term results of a prospective randomized clinical and manometric study. Evaluation of Healing and Complications After Lateral Internal Sphincterotomy for Chronic Anal Fissure: Marginal Suture of Incision vs. Open Left Incision: Prospective, Randomized, Controlled Study Percutaneous Posterior Tibial Nerve Stimulation vs Perianal Application of Glyceryl Trinitrate Ointment in the Treatment of Chronic Anal Fissure: A Randomized Clinical Trial Randomized clinical trial of transcutaneous electrical posterior tibial nerve stimulation versus lateral internal sphincterotomy for treatment of chronic anal fissure. Treatment of anal fissures using a combination of minoxidil and lignocaine: a randomized, double-blind trial. [Surgical or biologic sphincterotomy in the treatment of chronic anal fissure]. Surgical treatment of chronic fissure-in-ano: a prospective randomised study. Comparison of Botulinum Toxin Injection and Lateral Internal Sphincterotomy for the Treatment of Chronic Anal Fissure Randomized clinical trial comparing oral nifedipine with lateral anal sphincterotomy and tailored sphincterotomy 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 Effectiveness of higher doses of botulinum toxin to induce healing in patients with chronic anal fissures. Glyceryl trinitrate ointment for the treatment of chronic anal fissure Botulinum toxin injection versus internal anal sphincterotomy for the treatment of chronic anal fissure Open versus closed lateral sphincterotomy performed as an outpatient procedure under local anesthesia for chronic anal fissure: prospective randomized study of clinical and manometric longterm results. Topical anal fissure treatment: placebo-controlled study of mononitrate and trinitrate therapies Internal sphincterotomy versus topical nitroglycerin ointment for chronic anal fissure. Fine-tuning of the Extent of Lateral Internal Sphincterotomy: Spasm-controlled vs. up to the Fissure Apex Treatment of chronic anal fissure with topical glyceryl trinitrate: a double-blind, placebo-controlled trial. Topical nitroglycerin versus lateral internal sphincterotomy for chronic anal fissure: prospective, randomized trial Randomized, double-blind trial comparing topical nitroglycerine with xylocaine and Proctosedyl in idiopathic chronic anal fissure. Removal of hypertrophied anal
papillae and fibrous anal polyps increases patient satisfaction
after anal fissure surgery [A prospective, randomized double-blind study on the treatment of anal fissures with Nitroglycerin ointment]. Isosorbide dinitrate in the treatment of anal fissure: a randomised, prospective, double blind, placebo-controlled trial. Glyceryl trinitratevs. sphincterotomy for treatment of chronic fissure-in-ano Extent of Lateral Internal Sphincterotomy: Up to the Dentate Line or Up to the Fissure Apex? Lateral internal sphincterotomy is not redundant in the era of glyceryl trinitrate therapy for chronic anal fissure Solcoderm as alternative conservative treatment for acute anal fissure: a controlled clinical study. The conservative treatment of fissure‐in‐ano Comparison of topical glyceryl trinitrate with lignocaine ointment for treatment of anal fissure: a randomised controlled trial. A Double-Blind Randomized Trial Comparing the Effectiveness and Safety of Nifedipine and Isosorbide Dinitrate in Chronic Anal Fissure.
PURPOSE : This study was design ed to assess differences between lateral internal anal sphincterotomy and anal advancement flap for chronic anal fissure . METHODS : Forty patients with chronic anal fissure were prospect ively studied . Patients r and omized to the sphincterotomy group ( n=20 ; median age , 34 ( range , 16–61 ) years ) underwent lateral internal anal sphincterotomy . Patients r and omized to the  flap group ( n=20 ; median age , 32 ( range , 20–44 ) years ) had an anal advancement flap . RESULTS : All fissures in the sphincterotomy group healed following surgery compared with three patients that failed to heal in the flap group ( P= 0.12 ) . No patient in either group was incontinent to any degree following surgery . Patient satisfaction with surgery was similar in both groups . CONCLUSION : Anal advancement flap is an alternative to lateral sphincterotomy for chronic anal fissure Chronic anal fissure is the most common cause of anal pain associated with internal anal sphincter hypertonia . Reduction of hypertonocity is a special treatment for fissure healing . For this purpose chronic anal fissures were conventionally treated by anal dilatation or by lateral sphincterotomy . However , both of these methods may cause a degree of incontinence in some patients . The uptake of medical therapies that create a reversible chemical sphincterotomy has recently become widespread . The aim of this prospect i ve clinical trial study was to assess the effectiveness of nifedipine  in healing anal fissure , a calcium channel blocker that reduces sphincter pressure . A single-blind r and omized comparative trial was setup to compare traditional treatment with stool softeners and 2 % lidocaine cream against 0.5 % nifedipine cream for 4 weeks . 110 patients were included in this study , 60 patients in the nifedipine group and 50 patients in the control group and the therapeutic outcome and side effects were recorded . Healing had occurred in 70 % of patients in the nifedipine group and in 12 % of patients in the control group after 4 weeks treatment ( P < 0.005 ) . Recurrence of symptoms occurred in four of healed patients in the nifedipine group and three patients in the control group in two months . The final result of nifedipine application after 12 months follow up was recurrence in 11 patients ( 26.19 % ) . Mild headache occurred in four patients ( 6.6 % ) of the nifedipine group . Patients in the nifedipine group showed significant healing and relief from pain compared with patients in the control group . Recurrence rate with nifedipine use in spite of control of predisposing factors such as constipation was significant . Another finding was low complication rate with this treatment Background Troublesome fecal incontinence following a lateral internal sphincterotomy is often attributed to faulty surgical technique . However , it may be associated with coexisting occult sphincter defects . Whether continence is related to the extent of sphincterotomy remains debatable . The aim of the study is to identify fecal incontinence related to chronic anal fissure before and after lateral internal sphincterotomy and its relationship to the extent of internal anal sphincter division . Methods One hundred eight patients with chronic anal fissure were prospect ively studied before and after lateral internal sphincterotomy . A question naire was completed for each patient before and after surgery with regard to any degree of fecal incontinence . Fecal incontinence severity index was assessed using the Clevel and Clinic Incontinence Score .  The patients with preoperative perfect continence were r and omized into two groups ( 46 patients in each group ) : Group 1 underwent traditional lateral internal sphincterotomy ( up to the dentate line ) and Group 2 were underwent a conservative internal anal sphincterotomy ( up to the height of the fissure apex or just below it ) . Results Minor degrees of incontinence were present before surgery in 16 patients ( 14.8 % ) . Results of the r and omized trial revealed that temporary postoperative incontinence was newly developed in 6/92 of patients ( 6.52 % ) who did not have it before surgery . Five of the six ( 10.86 % ) were in Group 1 one ( 2.17 % ) was in Group 2 ( p = 0.039 ) . Persistent incontinence occurred in two in Group 1 ( 4.35 % ) . All of them were females . All have had a history of one or more vaginal deliveries .  Conclusion A mild degree of fecal incontinence may be associated with chronic anal fissure at presentation rather than as a result of internal sphincterotomy . Troublesome fecal incontinence after lateral internal sphincterotomy is uncommon . Sphincterotomy up to the dentate line provided faster pain relief and faster anal fissure healing , but it was associated with a significant postoperative alteration in fecal incontinence than was sphincterotomy up to the fissure apex . Care should be exercised in female patients with a history of previous obstetric trauma , as internal anal sphincter division may further compromise sphincter function BACKGROUND 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 Chronic Anal Fissure ( CAF ) is common perineal condition and well-known painful entity . St and ard surgical treatment even though available , may require long hospital stay and sometimes have worrying complications like anal incontinence . So non-surgical treatment , Glyceryl Trinitrate has been shown to be an effective for chronic anal fissure . It decreases anal tone and ultimately heals the anal fissure . The present study is the attempt to know the efficacy of 0.2 % Glyceryl Trinitrate ointment in the treatment of chronic anal fissure and to compare the effectiveness of 0.2 % Glyceryl Trinitrate ointment ( GTN ) versus fissurectomy with lateral internal sphincterotomy ( LIS ) and fissurectomy with posterior internal sphincterotomy ( PIS ) in the management of chronic anal fissure . This is a prospect i ve comparative study of management of chronic anal fissure done in our hospital during the period of one and half year from October 2005 to March 2007 . Thirty patients treated with 0.2 % Glyceryl Trinitrate ointment and 30 patients treated with fissurectomy and lateral internal sphincterotomy and 30 patients treated with posterior internal sphincterotomy , for chronic anal fissure were selected for study . A single br and of 0.2 % Glyceryl Trinitrate ointment ( Nitrogesic ) used for trial arm . Dose of administration was 1.5 cm to 2 cm in the anal canal with device provided by manufacturers of the proprietary preparation and applied twice a daily for 12 weeks . Patients were followed up for 12 weeks and thereafter evaluated for relief of symptoms in all three groups . Observations were recorded at 2 weeks ; 6 weeks and 12 weeks of follow up period , regarding symptoms like pain and bleeding during defecation , healing of CAF and also for side effects like headache in GTN group and flatus , fecal incontinence in surgical groups . Data collected in proforma and analyzed . Study revealed CAF was more in male 59 patients ( 66 % ) than the female 31 patients ( 34 % ) , the ratio being 1 : 0.52 . The maximum number of patients was encountered in the age group of 20 to 40 years with mean duration of age 34.14 years . In all three groups symptoms like pain , bleeding , constipation and sphincter spasm were present . Sentinel pile was present in 56 % of the patients . Common site of fissure was found to be posterior in 94 % of patients . Observations with respect to relief of pain , no bleeding and healing were recorded at 2 , 6 and 12 weeks of duration . Lateral sphincterotomy remains effective but should be reserved for the patients who fail to respond to initial chemical sphincterotomy or GTN therapy . GTN is good alternative mode of therapy for patients who refuse surgery and prefer medical line of treatment Purpose Lateral internal sphincterotomy has been the gold st and ard treatment for chronic anal fissure , but it still carries the risk of permanent damage of the anal sphincter , which has led to the implementation of alternative treatment like botulinum toxin injection . The aim of this r and omized prospect i ve controlled trial was to compare the efficacy and morbidity of botulinum toxin injection and lateral internal sphincterotomy in the treatment of chronic anal fissure . Methods Fifty consecutive adults with chronic anal fissure were r and omly treated with either lateral internal sphincterotomy or botulinum toxin ( BT ) injection with 50 U BT into the internal sphincter . The complications , healing and recurrence rate , and incontinence score were assessed 2 , 3 , 6 , 12 months after the procedure . Results Inspection at the 2-month visit revealed complete healing of the fissure in 11 ( 44 % ) of the patients in the BT group and 22 ( 88 % ) of the patients in the lateral internal sphincterotomy ( LIS ) group ( p = 0.001 ) . At the 3-month visit , there was no significant difference between the two groups in healing . The overall recurrence rate after 6 months in the BT group was higher than in the LIS group ( p < 0.05 ) . In the 3-month follow-up , the LIS group had a higher rate of anal incontinence compared to the BT group ( p < 0.05 ) . The final percentage of incontinence was 4 % in the LIS group ( p > 0.05 ) . Conclusions The treatment of chronic anal fissure must be individualized depending on the different clinical profiles of patients . Botulinum toxin injection has a higher recurrence rate than LIS , and LIS provides rapid and permanent recovery . However , LIS carries a higher risk of anal incontinence in patients 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 ) 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 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 BACKGROUND AND OBJECTIVE The function of the internal sphincter is disturbed in patients with chronic anal fissure due to persistent hypertonia and it may lead to a certain degree of incontinence . Our aim is to assess the results of lateral internal sphincterotomy and to identify any degree of incontinence related to the disease . METHODS This prospect i ve study included a review of all patients operated upon by the authors who performed division of the internal sphincter at or below the upper limit of the fissure .  A question naire was completed by each patient before surgery and then after surgery with regard to any degree of incontinence such as soiling of underclothes , control of flatus and accidental bowel motion . RESULTS 126 patients with chronic anal fissure were studied . The male to female ratio was 0.8:1 . Minor degrees of incontinence were present prior to surgery in 35 patients ( 28 % ) and in 31 ( 25 % ) patients after surgery , the majority of them were incontinent before surgery . CONCLUSION Based on the results of this study , minor degrees of incontinence could be a symptom of chronic anal fissure and not the sequelae of lateral internal sphincterotomy BACKGROUND Anal fissure is one of the most common anal-rectum diseases , and approximately 10 percent patients with chronic anal fissure ultimately receive surgery . Relieving postoperative pain and protecting functions of the sphincter are central issues for coloproctologists . OBJECTIVE To evaluate the efficacy and safety of anoplasty in the treatment of chronic anal fissures . DESIGN , SETTING , PARTICIPANTS AND INTERVENTIONS In this prospect i ve , multicenter , r and omized controlled trial , 120 adult patients with chronic anal fissure were referred from Department of Coloproctology of Yueyang Hospital of Integrated Traditional Chinese Medicine Affiliated to Shanghai University of Traditional Chinese Medicine , Shanghai Ninth People 's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine and Shanghai Municipal Hospital of Traditional Chinese Medicine . The patients were enrolled from January 2009 to April 2010 and r and omly divided into study ( mucosa advancement flap anoplasty , abbreviated as anoplasty ) group and control ( fissurectomy ) group . The two groups were assessed separately , and the main outcome measures were observed for 2 weeks , with a short-term follow-up for 6 weeks . MAIN OUTCOME MEASURES Degree of pain , haemorrhage and anal canal pressure were observed and recorded preoperatively , and on the third day , the fourteenth day and the sixth week postoperatively . The wound healing time was also recorded . Surgical complications of the two groups were recorded and compared on the third day and the sixth week postoperatively . The curative effects associated with the surgery were analyzed on the fourteenth day and the sixth week after surgery and the therapeutic results were evaluated . RESULTS Three patients were dropped out due to the early discharge from hospital and losing connection ( 1 in study group and 2 in control group ) . Overall the surgery showed that the anoplasty group had better results than the fissurectomy group in the curative effect on the sixth week after operation ( P<0.05 ) . Time of wound healing in the anoplasty group was ( 17.22 ± 4.41 ) d and was better than ( 21.24 ± 7.44 ) d of the fissurectomy group ( P<0.05 ) . Concerning the relief of wound pain , the anoplasty group achieved better results than the fissurectomy group at the third day , the fourteenth day and the sixth week after operation ( P<0.05 ) . Anoplasty reduced bleeding and had better efficacy than the fissurectomy at the third day and the fourteenth day after operation ( P<0.05 ) , however , there was no statistical difference at the sixth week after operation ( P>0.05 ) . There were no significant differences in relieving the anal canal pressure ( P>0.05 ) and the surgical complications ( dysuria , edema of anal margin , fever , infection , anal incontinence and anal deformation ) between the two groups ( P>0.05 ) . None of the patients suffered postoperative complications by the sixth week after operation . Furthermore , there was no recurrence in either of the two groups at six weeks after operation . CONCLUSION The results indicate that anoplasty for chronic anal fissures has advantages such as better therapeutic effects , less postoperative pain , a shorter healing time and no incidence of anal incontinence 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 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 Abstract . Mean maximum anal resting pressure is directly related to the activity of the smooth muscles of the internal and external sphincters and has been found to be increased in the patients of anal fissure . It has been shown that blood flow at the posterior midline of anoderm is inversely related to the mean maximum anal resting pressure , and topical application of glyceryl trinitrate ( GTN ) ointments is a very successful treatment . This r and omized study was design ed to evaluate the relative value of a nitroglycerin patch applied at a distance from the fissure site in healing anal fissure compared to GTN ointment and compared to surgical treatment .  Forty-two consecutive patients with chronic anal fissure of more than 4 months ' duration were r and omized into two equally sized groups : those in group A received 0.2 % GTN ointment while those in group B received a 10-mg nitroglycerin patch for 8 weeks . Patients were also asked to rate their pain intensity on a scale of 0–10 . Five patients were excluded for various reasons ; results were analyzed for the remaining 37 patients ( group A , n=18 ; group B , n=19 ) . A control group C consisted of 12 patients who underwent surgical treatment . Fissures healed completely in 12 of 18 ( 66.7 % ) patients in group A , 12 of 19 ( 63.2 % ) in group B and 11/12 ( 91.7 % ) in group C. The healing rates in groups A and B did not differ significantly ( P=0.7 ) , nor was there a difference between these and surgical group C ( P=0.13 ) . The local application of GTN ointment and the nitroglycerin patch are both effective , economical , and alternative treatment options for most patients with anal fissures PURPOSE : It is postulated that an anterior anal fissure can result from mucosal trauma occurring during distention of a rectocele and that repair of the rectocele by anterior levatorplasty can lead to healing of these anal fissures . This study was design ed to compare anterior levatorplasty with internal sphincterotomy for the management of anterior anal fissures in females with a rectocele . METHODS : From June 2000 until May 2002 , 54 consecutive females with an anterior anal fissure and a rectocele were r and omized to be managed by internal sphincterotomy or anterior levatorplasty . Preoperatively , manometry was performed , continence was measured using the Clevel and Clinic scoring system , pain scores were obtained using a visual analog scale , and the symptoms of bleeding and straining to defecate were assessed . Postoperatively , pain scores were obtained at Days 2 , 7 , and 21 . Manometry , continence scores , and resolution of symptoms were measured between 8 and 12 weeks . Patient satisfaction and fissure healing also were assessed between 8 and 12 weeks . The average length of follow-up was 20 ( range , 6–30 ) months . RESULTS : Postoperatively , lateral sphincterotomy caused a decrease in the resting pressures and anterior levatorplasty result ed in an increased length of the anal canal . Anterior levatorplasty also caused increased postoperative pain scores . There were no differences in fissure healing and patient satisfaction . CONCLUSIONS : These data suggest that anterior levatorplasty is an option for the management of patients with a rectocele , which may avoid the risk of incontinence with lateral internal sphincterotomy and better address the etiology of anterior anal fissures BACKGROUND AND STUDY AIMS Chemical sphincterotomy is a new way for the treatment of chronic anal fissure which avoids the risk of faecal incontinence associated with traditional surgical methods . The aim of this study was to compare topical Diltiazem with topical Glyceril trinitrate in the treatment of chronic anal fissure . PATIENTS AND METHODS 61 patients ( 10 Male , 51 Female ) between 16 - 81 years of age with chronic anal fissure were included in this prospect i ve , r and omized , double-blind trial . The patients were r and omly allocated to either Diltiazem gel ( 2 % ) or Glyceril trinitrate ointment ( 0.2 % ) and were asked to use the treatment twice daily for 8 weeks . Each patient was review ed every two weeks ; pain scores , healing and side effects were assessed . RESULTS Healing occurred in 33 of 36 ( 91.66 % ) patients treated with Diltiazem after 6 weeks and 15 of 25 ( 60 % ) patients treated with Glyceril trinitrate after 8 weeks which shows a significant difference in favour of Diltiazem ( P < 0.001 ) . The rest of the patients were either non-compliant or did not heal and underwent surgery . Headache occurred in all of the patients treated with Glyceril trinitrate but none of the patients treated with Diltiazem developed headache . The frequency of other side-effects was also less in patients treated with Diltiazem ( P < 0.001 ) . CONCLUSIONS Diltiazem gel was found to be superior to Glyceril trinitrate ointment due to significantly higher healing rate and fewer side-effects 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 PURPOSE Pneumatic balloon dilation has been shown to be effective in the management of  chronic anal fissure  , but its effect on the anal sphincter has not been fully investigated . The aim of this study was to evaluate prospect ively the clinical , anatomic , and functional pattern in a group of patients treated by pneumatic balloon dilation .  METHODS A series of 33 consecutive patients suffering from chronic anal fissure underwent pneumatic balloon dilation .  Anal manometry and ultrasonography were performed prior to and 6 to 12 months after the treatment . Manometry was accomplished by means of an endoanal 40-mm balloon inflated with a pressure of 1.4 atmospheres that was left in situ for six minutes under local anesthesia . All patients were interviewed daily for three days after surgery and then clinical ly evaluated between the third and fifth postoperative weeks . Most patients were interviewed after 25.7 ± 8.4 months ( mean ± st and ard deviation ) . Anal incontinence was evaluated by means of a vali date d score of 1 to 6 . RESULTS The chronic anal fissure healed between the third and fifth weeks in 31 patients ( 94 percent ) , who became asymptomatic 2.5 ± 1.4 days after pneumatic balloon dilation . None of them reported anal pain two years after the treatment ( n = 20 ) . The first post-pneumatic balloon  dilation defecation was painless in 27 cases ( 82 percent ) . Two multiparous females ( 6 percent of the patients ) complained of minor transient anal incontinence ( score , 3 ) . Chronic anal fissure recurred in one case ( 3 percent ) after treatment . At manometry , the preoperative anal resting pressure decreased from 91 ± 11.2 to 70.5 ± 5.6 and to 78 ± 5.7 mmHg , 6 and 12 months after pneumatic balloon dilation , respectively ( P < 0.0001 ) . Anal ultrasonography did not show any significant sphincter defect . CONCLUSIONS Pneumatic balloon dilation seems to be an effective , safe , easy procedure that decreases anal resting pressure without endosonographically detectable significant sphincter damage 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 Fissure in ano is a very common disorder of the anorectal region . Internal sphincter hypertonia with decreased relaxation coupled with mucosal ischemia of posterior anal canal are the major pathologies in chronic anal fissure ( CAF ) . Though lateral internal sphincterotomy ( LIS ) remains the gold st and ard of treatment for the disease , it is accompanied by the potential complication of incontinence to both flatus and faecal matter . The aim of our study was to explore the role of topical diltiazem as an effective and a safe alternative to sphincterotomy for chronic anal fissure . Ninety patients with CAF were r and omly assigned to group A and group B , with 45 patients each . Group A patients received 2 % diltiazem topical application , twice daily , and group B patients underwent LIS . All the patients were review ed at first , fourth and sixth week after initiation of treatment . Visual analogue scores for pain and healing of fissure by visual inspection were recorded and compared . In group A , 71 % had complete healing of fissure at 6 weeks , with fair amount of pain relief ( mean VAS—3.38 ) , and in group B , 96 % showed healing of fissure , with excellent pain relief ( mean VAS—1.87 ) . Headache and flushing were noted in two patients in group A while no patients in group B developed incontinence . We conclude that LIS is more effective than topical diltiazem in the treatment of CAF . Topical diltiazem may be employed as an initial conservative treatment option before considering the surgical alternative OBJECTIVE To compare the symptomatic relief , healing and side-effects of topical diltiazem ( DTZ ) and glyceryl trinitrate in the treatment of chronic anal fissure .  STUDY DESIGN R and omized controlled trial . PLACE AND DURATION OF STUDY The Surgical Outpatient Department of Civil Hospital , Karachi , from March 2006 to February 2007 . METHODOLOGY Patients with chronic anal fissure were included in the study and r and omized to two groups . One group was administered topical 2 % diltiazem hydrochloride and other was given 0.2 % glyceryl trinitrate ( GTN ) , perianally twice daily for 8 weeks . Patients with anal fissure due to other diseases like inflammatory bowel disease , malignancy , sexually transmitted diseases , previous treatment with local ointment or surgery ; patients who required anal surgery for any concurrent disease like hemorrhoids , pregnant women and patients with significant cardiovascular conditions were excluded . There were four follow-up sessions during the course of treatment . Healing and side-effects were recorded . Analysis was done by SPSS version 10 on intention-to-treat basis . Chi-square was used where appropriate . RESULTS Eighty patients with symptomatic chronic anal fissure were included in the study and equally divided into two groups . After 8 weeks of treatment healing occurred in 31 of 40 patients treated with diltiazem and 33 of 40 patients treated with GTN ( p = 0.576 ) . There were less side-effects with DTZ ( n=13 ) than with GTN ( n=29 , p < 0.001 ] . In particular , headache occurred more commonly with GTN ( n=27 ) than with DTZ ( n=9 , p < 0.0001 ) . CONCLUSION Diltiazem hydrochloride and glyceryl trinitrate were equally effective in healing chronic anal fissure .  Diltiazem caused fewer side-effects particularly headache than glyceryl trinitrate ointment . Diltiazem may be the first-line treatment for chemical sphincterotomy for the chronic anal fissure 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 Purpose This prospect i ve , r and omized , controlled trial was design ed to compare the clinical , functional , and morphologic results of pneumatic balloon dilatation with lateral internal sphincterotomy for the treatment of chronic anal fissure . Methods All patients with symptomatic chronic anal fissure were r and omly assigned to  pneumatic balloon dilatation or lateral internal sphincterotomy  and invited to complete a st and ardized question naire inquiring about their symptoms . Anal ultrasonography and anal manometry were performed before and six months after surgery . A proctologic examination was performed between the fifth and sixth postoperative weeks . Anal continence , scored by using a vali date d continence grading scale , was evaluated preoperatively at 1 and 6 weeks and at 12 and 24 months . Results Fifty-three patients , who satisfied selection criteria , were enrolled in the trial . Four patients ( 7.5 percent ) were lost to follow-up . Twenty-four patients ( 11 males ; mean age , 42 ± 8.2 years ) underwent pneumatic balloon dilatation and 25 patients ( 10 males ; mean age , 44 ± 7.3 years ) underwent lateral internal sphincterotomy . Fissure-healing rates were 83.3 percent in the pneumatic balloon dilatation and 92 percent in the lateral internal sphincterotomy group . Recurrent anal fissure was observed in one patient ( 4 percent ) after lateral internal sphincterotomy . At anal manometry , mean resting pressure decrements obtained after pneumatic balloon dilatation and lateral internal sphincterotomy were 30.5 and 34.3 percent , respectively . After pneumatic balloon dilatation , anal ultrasonography did not show any significant sphincter damage . At 24-month follow-up , the incidence of incontinence , irrespective of severity , was 0 percent in the pneumatic balloon dilatation group and 16 percent in the lateral internal sphincterotomy group ( P < 0.0001 ) . Conclusions As lateral internal sphincterotomy , pneumatic balloon dilatation grants a high anal fissure-healing rate but with a statistically significant reduction in postoperative anal incontinence Background Although lateral internal sphincterotomy has been the gold st and ard of treatment for chronic anal fissure , the main concern remains its effects on anal continence . Intrasphincteric injection of botulinum toxin seems to be a reliable option providing temporary alleviation of sphincter spasm and allowing the fissure to heal . The aim of the present prospect i ve controlled r and omized study was to compare the outcome of lateral internal sphincterotomy and botulinum toxin injection treatments in patients with uncomplicated chronic anal fissure . Methods Eighty consecutive patients with uncomplicated chronic anal fissure who had failed conservative treatment were r and omized to receive either intrasphincteric injection of botulinum toxin ( BT ) or lateral internal sphincterotomy ( LIS ) .  Postoperative pain relief , healing of fissure , continence scores , and fissure relapse during 18 weeks of follow-up were the outcomes assessed . Results There was a statistically significantly higher healing in the LIS group than the BT group ( p = 0.0086 and 95 % CI = 7.38–45.69 % ) . In addition , LIS was associated with a high rate of anal incontinence as compared to BT ( p = 0.0338 and 95 % CI = −1.64–27.53 % ) . The recurrence rate in the BT group was significantly higher statistically than that in the LIS group ( p = 0.0111 and 95 % CI = 6.68–46.13 % ) . Conclusions Surgical internal sphincterotomy has a higher healing rate and a lower recurrence rate than intrasphincteric injection of botulinum toxin in the treatment of uncomplicated chronic anal fissure . Injection of botulinum toxin , however , is a simple noninvasive technique that avoids the greater risk of incontinence . It could be used as the first therapeutic approach in patients without clinical risk factors of recurrence 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 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 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 Background Several surgical methods are accepted for the treatment of chronic anal fissure . The most popular are anal dilatation ( AD ) and left lateral sphincterotomy ( LLS ) . The objective of the current study was to prospect ively evaluate the results of these two procedures in terms of recurrence rate , complications and patient satisfaction . Methods The study enrolled all patients who required operation for chronic anal fissure in the Division of General Surgery , Campus Golda , Rabin Medical Center , between the years 1997 and 2001 . Exclusion criteria were acute anal fissure or inflammatory bowel disease . Results A total of 108 patients participated in the study , at an average age of 42.4 years ( SD=12.5 ) . The patients were r and omly assigned to two groups ; one for LLS ( 53 patients , 49.1 % ) and one for AD ( 55 patients , 50.9 % ) . The study protocol included a question naire and a physical examination performed 1 , 2 , 3 , 6 and 12 months after operation . The question naire contained questions about pain , bloody stool , incontinence for gas , fluid or hard feces , during the day or night , and soiling . The patients were also asked about their satisfaction on an analog scale from 1 to 10 . The average follow-up was 11.2 months ( SD=4.1 ) . Minor incontinence occurred in 8 patients of AD group and in 2 patients of LLS group ( p<0.005 ) . Recurrence occurred in 6 cases of the AD group and in one case of the LLS group ( p<0.003 ) . Satisfaction score was insignificantly higher in the LLS group ( 9.1±0.8 in the LLS group and 7.4±2.0 in the AD group ) . Conclusions These results suggest that LLS is the preferred method for the treatment for chronic anal fissure BACKGROUND Chronic anal fissure ( CAF ) is perpetuated by high sphincter pressures and secondary local ischemia . Pharmacological approaches include topical nitrates and botulinum toxin ( BT ) , which both help to decrease the sphincter pressure . AIMS & OBJECTIVES The aims of the present study were to assess the efficacy and safety of BT injection and combined treatment with BT injection and lowered dose glyceryltrinitrate ( GTN ) cream for the treatment of CAF . We hypothesised that combined treatment would have a synergistic effect on healing . METHODS Forty-one consecutive patients with CAF were r and omly assigned to receive one of the following treatments : Group A , injection of BT ( 20 U into internal anal sphincter ) and Group B , BT injection ( 20 units ) and subsequent thrice daily topical applications of half-dose 0.2 % GTN cream for 6 weeks . Patients were followed up at 6 and 12 weeks and were assessed for healing of anal fissure , by means of visual inspection using fissure grade s ; for faecal incontinence , using Clevel and Clinic incontinence scores ; and for fissure pain and headache using a numeric pain rating scale . RESULTS Fissure healing was similar in the two groups at both 6 ( 30 % in BT and GTN and 33 % in BT only ) and 12 weeks ( 50 % in BT and GTN vs 57 % in BT-only group ) . Neither the change in pain score from 6 to 12 weeks , nor the overall level of pain was significantly different in the 2 groups . Moderate or severe headaches were suffered by 58 % of patients using GTN . CONCLUSION Single-agent treatment by means of BT injection alone was well tolerated compared with combination treatment with BT injection and GTN cream , with no significant differences in healing of CAF observed in this small study 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 Purpose To compare the healing properties of lateral internal sphincterotomy ( LIS ) and isosorbide dinitrate ( ISDN ) ointment for chronic anal fissure . Methods Patients with a chronic anal fissure were r and omly assigned to a group treated with ISDN ointment ( n = 105 ) or a group treated with LIS ( n = 102 ) . The same investigators examined the patients in a blinded manner , 1 , 2 , 3 , 6 , and 12 months after the treatments . Results The anal fissure had healed completely by 4 weeks in 64.7 versus 92.2 % , and by 6 months in 77.1 versus 97.1 % of the ISDN and LIS group patients , respectively . At 12 months , the recurrence rates were 4.8 versus 1 % for the ISDN and LIS groups , respectively , and the success rates of the treatments were 72.4 versus 96.1 % , respectively . Six patients in the LIS group experienced minor fecal incontinence , and seven ( 6.7 % ) patients in the ISDN group experienced headaches that responded well to paracetamol . Conclusion ISDN ointment was reported by all patients to be easy to use . Although its success rate was lower than that of surgery , ISDN can be offered to selected patients with a chronic anal fissure , as it has a low recurrence rate and rare side effects are rare 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 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 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 Background Lateral internal sphincterotomy has been proven highly effective in curing anal fissure but with a high incidence of postoperative incontinence . Objective We compared conventional lateral internal sphincterotomy , V-Y advancement flap , and combined tailored lateral internal sphincterotomy with V-Y advancement flap in treating anal fissure . Patients Consecutive patients treated for anal fissure at our colorectal unit were evaluated for inclusion . Participants were r and omly allocated to receive conventional sphincterotomy ( GI ) , V-Y advancement flap ( GII ) , or combined tailored lateral sphincterotomy with V-Y advancement l flap (GIII).Main Outcome Measures The primary outcome measure was the incontinence rate ; secondary outcomes included healing rate , operative time , anal manometery , and recurrence rate . Results One hundred fifty patients with chronic anal fissure were r and omized . Healing rate after 1 year was 84 % in GI , 48 % in GII , and 94 % in GIII , respectively ( P = 0.001 ) . The recurrence rate was 4 % in G1 , 22 % in GII , and 2 % in GIII ( P = 0.01 ) . Incontinence rate was 14 % in GI , 0 % in GII , and 2 % in GIII ( P = 0.03 ) . Conclusion Although all three procedures are simple and easy to perform , tailored lateral internal sphincterotomy with V-YF appears to produce the greatest healing rate , with the fewest complications and less rate of recurrence OBJECTIVES : The aim of this study is to evaluate the effectiveness and complications associated with combined topical diltiazem cream and botulinum toxin A injection versus partial lateral internal sphincterotomy in chronic anal fissure . DESIGN : This study is a parallel , r and omized controlled trial ( using the block r and omization method ) . SETTING : This study was performed at a university hospital in Iran . PARTICIPANTS : Ninety-nine patients who had chronic anal fissures were included . INTERVENTION : A total of 99 patients were r and omly assigned to 2 groups ; the first group received combined topical diltiazem ointment ( for 6 weeks ) and botulinum toxin A injection ( once ) ( n = 49 ) , and the second group received partial lateral internal sphincterotomy ( n = 50 ) . All the patients were followed up for 1 year . MAIN OUTCOME MEASURES : The primary outcomes measured were the healing of the anal fissure and the development of incontinence as the major adverse event during the 1-year follow-up period . RESULTS : The overall healing rate was 65 % and 94 % in the botulinum toxin A – diltiazem and partial lateral internal sphincterotomy groups ( p < 0.001 ) . The patients in the partial lateral internal sphincterotomy group experienced significantly higher incontinence scores ( p = 0.04 ) according to the Clevel and Clinic Florida-Fecal Incontinence scoring system . In patients who had chronic anal fissure for ⩽12 months , no statistical difference was observed in the healing rate between the botulinum toxin A – diltiazem and partial lateral internal sphincterotomy groups ( 100 % vs 100 % ) . However , in the patients with longer chronic fissures , the healing rate was significantly higher in the partial lateral internal sphincterotomy group ( 86 % [ 18/21 ] vs 23 % [ 5/21 ] , p < 0.001 ) . LIMITATIONS : The 1-year follow-up period , subjective definitions of itching , and lack of anorectal manometry examinations and data regarding the effect of each treatment on anal sphincter pressure at rest and contraction are the key limitations of this study . CONCLUSION : Combined botulinum toxin A injection with a topical application of diltiazem could be as effective as partial lateral internal sphincterotomy in the treatment of chronic anal fissure in patients who have chronic anal fissure for ⩽12 months . However , in chronic anal fissures of longer duration , partial lateral internal sphincterotomy is associated with a significantly higher cure rate 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 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 AIM The results of controlled-intermittent anal dilatation ( CIAD ) or lateral internal sphincterotomy ( LIS ) in the treatment of chronic anal fissures are presented . MATERIAL AND METHODS Forty patients who were r and omized to two groups underwent CIAD or a LIS .  The pre- and post-operative mean anal canal resting pressures ( MACRPs ) and symptoms were recorded and the results were compared . RESULTS Two months post-operatively , 18 patients in the CIAD group and 17 patients in the LIS group had healed completely , and had no anal incontinence or other complications . The post-operative improvement in pain , bleeding , and constipation did not differ significantly between the two groups . In the CIAD and LIS groups , the pre-operative MACRPs were 89.7+/-16.5 and 87.6+/-12.3 mmHg , respectively ; 2 months post-operatively , the MACRPs had significantly decreased to 76.9+/-13.7 and 78.1+/-11.3 mmHg in the CIAD and LIS groups , respectively . No statistical difference existed in the pre- or post-treatment MACRPs between the groups . CONCLUSION CIAD applied with a st and ardized technique reduced anal canal resting pressure and provided symptomatic healing that was equivalent to a LIS . Since there were no findings of incontinence , or situations which result ed in sphincter damage , we conclude that CIAD is suitable for patients with chronic anal fissures because it is less invasive than LIS , with equivalent efficacy and safety . In addition , the CIAD method may be an alternative procedure in older and multiparous women who has a higher risk of incontinence BACKGROUND 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 Purpose Internal sphincterotomy remains the st and ard for treatment of anal fissure , but it is associated with risks of infection , bleeding , and incontinence . Recent studies have suggested that the complications after lateral internal sphincterotomy are related to surgical technique . This study was design ed to assess the incidence of early and late complications after lateral internal sphincterotomy with marginal sutured incision .  Fissure healing , pain , and complications were compared in patients undergoing a procedure involving three interrupted marginal sutures after open lateral internal sphincterotomy procedure . Methods Ninety patients of chronic anal fissure were r and omly assigned to two groups . Both groups received open lateral internal sphincterotomy via st and ardized method . The incisions of the patients in Group 1 ( n = 45 ) were sutured marginally with three interrupted sutures using 2 - 0 chromic catgut , whereas the incisions of the patients in Group 2 ( n = 45 ) were left open . The patients were assessed at 12 weeks postoperatively by an independent observer . Results The fissure-healing rate was not significantly different in both groups ( 95 and 93.1 percent , respectively ) . The pain score was slightly higher in Group 2 , and it was statistically significant . Four cases of bleeding and two abscesses were observed in Group 2 . These complications were not observed in Group 1 . One case of incontinence was observed at the beginning in Group 1 and four in Group 2 , but the incontinence was transient in both cases . Conclusions Marginal sutures of incision after lateral internal sphincterotomy may be beneficial to reduce complications related to early wound healing BACKGROUND : Current therapeutic guidelines for the treatment of chronic anal fissure establish a medical approach as the first step . Glyceryl trinitrate ointment is the most popular of the available topical treatments in Spain but it is associated with the appearance of headache . OBJECTIVE : The purpose of this study was to compare the compliance rate among patients receiving glyceryl trinitrate treatment for chronic anal fissure with that among patients receiving percutaneous posterior tibial nerve stimulation .  DESIGN : This was a prospect i ve r and omized study . SETTING S : The study was conducted at Garcilaso Clinic ( Madrid , Spain ) . PATIENTS : Subjects with persistent anal fissure despite hygiene and dietary measures applied over at least a 6-week period were included . INTERVENTIONS : Study interventions were perianal application of glyceryl trinitrate ointment ( twice daily for 8 weeks ) and percutaneous posterior tibial nerve stimulation ( 30-minute session 2 days per week for 8 weeks ) . MAIN OUTCOME MEASURES : Compliance with the treatment and healing rate of chronic anal fissure in patients receiving glyceryl trinitrate ointment or undergoing percutaneous posterior tibial nerve stimulation  were evaluated . RESULTS : Forty patients were included in each group . In the glyceryl trinitrate ointment group , 15 % of the patients discontinued treatment because of disabling headaches . There were no adverse effects or treatment withdrawals in the percutaneous posterior tibial nerve stimulation group ( p = 0.033 ) . After 8 weeks of treatment , the healing rate in the percutaneous posterior tibial nerve stimulation group was 87.5 % vs 65.0 % in the glyceryl trinitrate ointment group ( p = 0.018 ) . LIMITATIONS : Because the patients were not blinded to the treatment , we can not rule out a placebo effect derived from the needle insertion in the percutaneous posterior tibial nerve stimulation group . CONCLUSIONS : Percutaneous posterior tibial nerve stimulation is a safe and effective alternative that is in some ways superior to glyceryl trinitrate ointment for the treatment of chronic anal fissure OBJECTIVES The objective of this study was to evaluate the efficacy of transcutaneous electrical posterior tibial nerve stimulation in treatment of patients with chronic anal fissure and to compare it with the conventional lateral internal sphincterotomy . PATIENTS AND METHODS Consecutive patients with chronic anal fissure were r and omly allocated into two treatment groups : transcutaneous electrical posterior tibial nerve stimulation group and lateral internal sphincterotomy group . The primary outcome measures were number of patients with clinical improvement and healed fissure . Secondary outcome measures were complications , VAS pain scores , Wexner 's constipation and Peascatori anal incontinence scores , anorectal manometry , and quality of life index . RESULTS Seventy-three patients were r and omized into two groups of 36 patients who were subjected to transcutaneous electrical nerve stimulation and 37 patients who underwent lateral internal sphincterotomy . All ( 100 % ) patients in lateral internal sphincterotomy group had clinical improvement at one month following the procedure in contrast to 27 ( 75 % ) patients in transcutaneous electrical nerve stimulation group . Recurrence of anal fissure after one year was reported in one ( 2.7 % ) and 11 ( 40.7 % ) patients in lateral internal sphincterotomy and transcutaneous electrical nerve stimulation groups respectively . Resting anal pressure and functional anal canal length were significantly reduced after lateral internal sphincterotomy . CONCLUSION Transcutaneous electrical posterior tibial nerve stimulation for treatment of chronic anal fissure is a novel , non-invasive procedure and has no complications . However , given the higher rate of clinical improvement and fissure healing and the lower rate of fissure recurrence , lateral internal sphincterotomy remains the gold st and ard for treating chronic anal fissure 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 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 A prospect i ve r and omised study compared anal dilatation ( n = 37 ) , posterior internal sphincterotomy ( n = 21 ) and lateral sphincterotomy ( n = 20 ) in the surgical treatment of chronic anal fissures in 78 consecutive patients . All the operations were performed under general anaesthesia using st and ard techniques . Anal dilatation relieved anal pain early ( immediate relief in 57 % of patients ; the mean pain-days + /- SD of 3.2 + /- 5.4 days ) . Anal fissures after this operation healed in a mean time + /- SD of 20.3 + /- 12.5 days , coming in second place to lateral sphincterotomy . Anal dilatation was followed by insignificant wound infection but its main disadvantage was a high rate of post operative anal incontinence ( in 24.3 % of patients ) . Fissurectomy and posterior internal sphincterotomy was followed by the longest period of post operative anal pain ( mean + /- SD of 32.4 + /- 10 days ) as compared to the other two operations . It was the least favourable operation . Lateral sphincterotomy was followed by early relief of pain ( immediate relief in 95 % of patients ) . It was not followed by wound infection . It had the quickest healing time for the fissures ( a mean + /- SD of 14.7 + /- 8.7 days ) . It was followed by anal incontinence in only one patient . In conclusion lateral sphincterotomy was the most favourable operation and it is perhaps the operation of choice to perform in patients with chronic anal fissures needing surgical treatment 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 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 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 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 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 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 BACKGROUND The aim of this prospect i ve r and omized trial was to compare the effectiveness and morbidity of open and closed sphincterotomy performed as an outpatient procedure under local anesthesia in the treatment of chronic anal fissure . STUDY DESIGN Eighty patients with chronic anal fissure were treated by open  ( group 1 ) or closed lateral internal sphincterotomy ( group 2 ) . Clinical and manometric results were recorded at the time of admission and at 1-week , 2-month , 6-month , 1-year , and 2-year followup visits . RESULTS Overall healing after 2 years was 92.5 % in the open sphincterotomy group and 90 % in the closed sphincterotomy group ( p > 0.05 ) . Fissures were notably less likely to heal in patients in whom the condition had been present for longer than 12 months and who had a sentinel pile before treatment . At the 2-year revision , incontinence was present in two patients ( 5 % ) in the open sphincterotomy group and one patient ( 2.5 % ) in the closed sphincterotomy group ( p > 0.05 ) . In all cases , the incontinence was mild ( < 4 , Clevel and score ) . Increased mean resting pressure ( 113.9 mmHg ) was found in patients with anal fissure before treatment compared with the healthy control group ( mean resting pressure = 66 mmHg ) ( p < 0.001 ) . The mean resting pressure in patients cured after 2 years was 75.65 mmHg , and in those with a recurrent fissure was 112.85 mmHg ( p < 0.001 ) . CONCLUSIONS Morbidity and recurrence were similar in open and closed sphincterotomies when the procedures were performed under local anesthetic , and sphincterotomy under local anesthesia as an outpatient procedure has several socioeconomic advantages ( high degree of satisfaction and comfort to the patient , rapid solution of the problem , and no admission to the hospital or an operating room and no preoperative studies ) 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 ) BACKGROUND Anal fissure is a common benign condition . An anorectal problem is defined as a split in the anal canal mucosa that extends from the dentate line to the anal verge . Chronic anal fissure is defined by a history of symptoms present for more than 2 months ' duration and with a triad of external skin tags , namely , a hypertrophied anal papilla , an ulcer with rolled edges , and a base exposing the internal sphincter . Because complications such as incontinence are associated with surgical treatment , chemical sphincterotomy is currently favored . OBJECTIVES The objective of this study is to compare the difference in outcome between open partial lateral anal sphincterotomy and application of topical 0.2 % nitroglycerin ointment for the treatment of chronic anal fissure . METHODS This was a quasi-experimental study carried out between January 16 , 2007 and January 15 , 2008 in the Surgical Department of Jinnah Hospital , Lahore , Pakistan . Sixty consecutive cases with a clinical diagnosis of chronic anal fissure were recruited in the study . All recruited patients met the study inclusion criteria and were r and omly assigned to one of the two groups . Group A was managed conservatively using topical 0.2 % nitroglycerin ointment , whereas Group B underwent open partial lateral anal sphincterotomy . Both groups were followed up at 1 week , 2 weeks , 4 weeks , and 6 weeks after the treatment . RESULTS All the patients complained of pain . A total of 43 ( 71.7 % ) patients had pain with constipation , whereas 31 ( 51.7 % ) patients had bleeding per rectum . Upon clinical ly examining the anal area , tenderness was elicited in all 60 ( 100 % ) patients . Group A included 30 ( 11 females and 19 males ) cases treated with topical 0.2 % nitroglycerin ointment and Group B included 30 ( 11 females and 19 males ) cases who underwent open partial lateral anal sphincterotomy . In Group A , only 15 patients with fissures were successfully treated ( 50 % ) . By contrast , 28 ( 93 % ) patients with fissures in Group B were successfully treated , and only two ( 7 % ) remained uncured . These two patients ( 6.6 % ) in Group B suffered from incontinence due to flatus and feces as a complication of the procedure . CONCLUSION This quasi-experimental study demonstrates that open partial lateral internal sphincterotomy is superior to topical 0.2 % nitroglycerin application in the treatment of chronic anal fissure , with good symptomatic relief , high rate of healing , fewer side effects , and a very low rate of early continence disturbances Purpose This study was design ed to compare the results of controlled lateral internal sphincterotomy  by using anal calibrators with those of sphincterotomy up to the fissure apex in a r and omized , prospect i ve fashion . Methods In the fissure apex group , sphincterotomy was extended to the level of the fissure apex , and in the spasm-controlled group , serial small sphincterotomies and anal caliber measurements followed until an anal caliber of 30 mm was obtained . Results The preoperative anal caliber was 24 ± 1.9 ( range , 20–28 ) mm and 24.9 ± 2.44 ( range , 19–28 ) mm in the spasm-controlled and fissure apex groups , respectively ( P = 0.127 ) . Postoperatively , the spasm-controlled group had a mean anal caliber of 31.5 ± 1.28 ( range , 30–32 ) mm , and the fissure apex group had 32.5 ± 2.33 ( range , 25–37 ) mm ( P = 0.035 ) . In the fissure apex group , a significant negative correlation was determined between the postoperative anal caliber and time of relief of pain ( r = −0.568 , P = 0.001 ) . The early ( 7 and 28 days ) postoperative anal incontinence scores were significantly higher in the fissure apex group ( P = 0.002 , P < 0.0001 , respectively ) . A significant positive correlation between the anal caliber measurements and anal incontinence scores at 28 days and 2 months also was noted in the fissure apex group ( r = 0.406 , P = 0.023 ; and r = 0.364 , P = 0.044 ) . Conclusions Controlled sphincterotomy provided a faster relief of pain , and it was associated with a lower rate of early postoperative disturbance of continence and an insignificantly lower rate of treatment failure compared with sphincterotomy up to the fissure apex 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 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 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 Abstract . Background : Hypertrophied anal papillae and fibrous anal polyps are frequently found in association with chronic fissure in ano . Usually , no specific attention is given to them and they are considered normal findings . The present prospect i ve study was aim ed at determining whether removal of hypertrophied anal papillae and fibrous anal polyps while dealing with chronic fissure in ano confers long-term benefit to patients . Methods : Between July 1999 and December 2000 , 140 patients undergoing anal sphincterotomy  were r and omized into two groups to have their fibrous polyps and hypertrophied anal papillae either removed by radiofrequency surgery or left intact . After two years , they underwent a detailed interview by an independent , masked investigator . Results : Overall 84 % of patients who had polyp and papilla removal rated the outcome of their surgery as excellent or good in comparison to 58 % of controls . The mean satisfaction grading was 9.2 on a visual analogue scale in the treatment group compared to 8.1 in controls ( p=0.004 ) . Conclusion : Removal of hypertrophied anal papillae and fibrous anal polyps should be an essential part of treatment of chronic fissure in ano . Persistence of these structures leaves behind a sense of incomplete treatment , reducing the overall satisfaction on the part of the patient . Radiofrequency procedure is useful in eradication of these concomitant pathologies 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 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 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 PURPOSE The aim of this r and omized , prospect i ve study was to compare the results of lateral internal sphincterotomy up to the dentate line or up to the fissure apex in the treatment of chronic anal fissure . METHODS Adult patients with chronic anal fissure were r and omly assigned to undergo lateral internal sphincterotomy to the level of the dentate line or to the level of the fissure apex . The patients were reexamined on postoperative Days 1 , 7 , 14 , 28 , and then at 2 and 12 months . RESULTS The time required for relief of pain postoperatively was 2.08 ± 1.44 days in the dentate line group , which was significantly shorter than that for the fissure apex group ( 4.72 ± 4.86 days ; P = 0.002 ) . Objective healing was achieved in 23.7 percent and 17.6 percent at 14 days , 97.4 percent and 88.2 percent at 28 days , and 100 percent and 97.7 percent at 2 months in the dentate line and fissure apex groups , respectively ( P > 0.05 for all comparisons ) . Only sphincterotomy up to the dentate line caused a significant change in anal incontinence ( P = 0.016 ) . Both groups had significantly lower anal resting pressures at 4 months postoperatively , compared with their corresponding preoperative levels ( P = 0.005 and P = 0.007 ) . The postoperative resting pressures did not differ significantly between the two groups ( P = 0.273 ) . By 12 months postoperatively , no treatment failures or recurrences were noted in the dentate line group ( 100 percent healing rate ) . In the fissure apex group , there was one nonhealing case and four recurrences , result ing in a 13.2 percent rate of treatment failure ( P = 0.058 ) . CONCLUSIONS Sphincterotomy up to the dentate line provided a faster and definitive healing within the time limits of this study , but it was associated with a significant alteration in anal continence . In turn , sphincterotomy up to the fissure apex was free of significant disturbance of continence , but its healing effect was slower and it was prone to an insignificantly higher rate of treatment failure 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 Acute anal fissure is a common malady that results in morbidity . If a patient is not responsive to conservative treatment , the current recommended treatments are either anal dilatation or lateral internal sphincterotomy . Both operations promise relatively good results , but the recurrence rates are about 16 per cent and 7 per cent , respectively . This fact , together with possible postoperative complications and costs , justifies trying conservative treatment before referring patients for surgery . The authors treated a study group of 25 patients with a topical application of Solcoderm . Another group of 25 patients concurrently treated with the usual conservative treatment served as the control group . Analysis of the early and late results proved Solcoderm to be simple to use , safe , without systemic side effects , cost-effective , and with statistically significant better outcome . Consequently , the authors believe that this method of treatment is justified in cases of acute and fissure and should be attempted before operation 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 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 BACKGROUND Chronic anal fissure is a common disease that is accompanied with pain and bleeding during defecation . Various surgical and non-surgical methods have been offered for the treatment of this condition . The aim of this r and omised clinical study was to compare the effectiveness and safety of nifedipine and isosorbide dinitrate ( ISDN ) in the treatment of chronic anal fissure . METHODS This double-blind clinical trial study was performed on patients aged 20 to 60 years old in 2012 to 2013 . The sample s with a primary diagnosis of chronic anal fissure were enrolled from the patients admitted to public treatment at the educational Imam Ali Clinic , Shahrekord , Iran by research ers and general surgery specialists . The patients were r and omised into two groups : nifedipine 0.3 % ( n = 35 ) or ISDN 0.2 % ( n = 35 ) applied three times a day for three weeks . The patients were examined on the 7th , 14th , and 21st days of treatment , and the symptoms including bleeding , pain , and healing status , as well as the side effects of the drugs , were assessed . Pain was evaluated using a visual analogue scale ( VAS ) . RESULTS After 21 days of follow-up , complete healing was achieved in 77.1 % ( n = 27 ) of patients in the nifedipine group and 51.4 % ( n = 18 ) in the ISDN group ( P = 0.05 ) . The mean VAS of the pain on day 21 was 0.91 ( SD 0.01 ) in the ISDN group and 0.45±0.78 in the nifedipine group , with a statistically significant difference ( P = 0.038 ) . The bleeding was similar in the two groups ( P = 0.498 ) . CONCLUSION In view of the findings on healing status and pain in the patients , nifedipine may be significantly more effective in the treatment of chronic anal fissure than ISDN
Botox and CCBs were equivalent to GTN in efficacy with fewer adverse events .
No medical therapy came close to the efficacy of surgical sphincterotomy , though none in these RCTs was associated with the risk of incontinence .
Medical therapy for chronic anal fissure , acute fissure and fissure in children may be applied with a chance of cure that is marginally better than placebo , and , for chronic fissure in adults , far less effective than surgery
BACKGROUND Because of the disability associated with surgery for anal fissure and the risk of incontinence , medical alternatives for surgery have been sought .
Most recently , pharmacologic methods that relax the anal smooth muscle , to accomplish reversibly what occurs in surgery , have been used to obtain fissure healing .
OBJECTIVES To assess the efficacy and morbidity of various medical therapies for anal fissure .