Surgical management of anal fissure versus Glyceryl Trinitrate ointment: a comparative prospective study

Sandeep Reddy, Krishnaprasad ., Sreeramulu P. N., Amal Abraham, Praveen G. P., Muni Reddy, Deepthi R.


Background: Anal fissure is common condition in general population which cause severe pain at the anal region while defecation and associated with bleeding. These symptoms cause reduction in quality of life with considerable morbidity. The objective of this study was to compare the difference in outcome between open lateral anal sphincterotomy and application of topical 0.2% nitroglycerin ointment for the treatment of chronic anal fissure and their individual efficacy.

Methods: 68 cases with a clinical diagnosis of anal fissure were recruited in the study. All selected patients met with inclusion criteria. Thus, selected cases were assigned to one of the other groups by odd and even method. Group A was managed conservatively using topical 0.2% nitroglycerin ointment, whereas Group B underwent open lateral anal sphincterotomy. Both groups were followed up at 3 week, 6 weeks, and 12 weeks, after the treatment.

Results: Among all the 68 patients, all patients had come with complaint of pain whereas 31 patients had bleeding per rectum along with pain. On clinical examination, hypertonic anal sphincter elicited in 47 patients, sentinel skin tag was noted in the 23 patients. Group A included 34 patients treated with topical 0.2% nitroglycerin ointment and group B included 34 patients who underwent lateral internal sphincterotomy. In group A, 25 (73.5%) patients treated successfully, 9 (26.4%) patients were uncured who underwent lateral anal sphincterotomy, with no fresh complaints during follow up. By contrast, all patients in group B were successfully treated and only one (0.03%) patient came with unexplained discomfort and one patient suffered from flatus incontinency.

Conclusions: This prospective study, demonstrates that open lateral internal sphincterotomy is superior to topical nitroglycerin application in the treatment of anal fissure with good symptomatic relief, high rate of healing with very low rate of early incontinence. Patients who are not willing to undergo surgery the glycerin trinitrate ointment can be used as medical line for fissure in ano.


Anal fissure, Glyceryl trinitrate ointment, Lateral anal sphincterotomy

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Richard LN. Medical treatments are only marginally better than placebo, but surgery may cause incontinence. BMJ. 2003;327(354):e355.

Farouk R, Duthie GS, MacGregor AB, Bartolo DC. Sustained internal sphincter hypertonia in patients with chronic anal fissure. Dis Colon Rectum. 1994;37:424-9

Schouten WR, Briel JW, Auwerda JJ, De Graaf EJ. Ischaemic nature of anal fissure. Br J Surg. 1996;83:63-5.

Lund JN, Scholefield JH. Glyceryl trinitrate is an effective treatment for anal fissure. Dis Colon Rectum. 1997;40:468-70.

Perrotti P, Bove A, Antropoli C, Molino D, Antropoli M, Balzano A, et al. Topical Nifedipine with Lidocaine ointment versus active control for treatment of chronic anal fissure: results of a prospective, randomized, double blind study. Dis Colon Rectum. 2002;45:1468-75.

Maria G, Cassetta E, Gui D, Brisinda G, Bentivoglio AR, Albanese A. A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med. 1998;338:217-20.

Sileri P, Mele A, Stolfi VM, Grande M, Sica G, Gentileschi P, et al. Medical and surgical treatment of chronic anal fissure: a prospective study. J Gastrointest Surg. 2007;11:1541-8.

Jonas M, Neal KR, Abercrombie JF, Scholefield JH. A randomized trial of oral versus topical diltiazem for chronic anal fissures. Dis Colon Rectum 2001;44:1074-8.

Essani R, Sarkisyan G, Beart RW, Ault G, Vukasin P, Kaiser AM. Cost-saving effect of treatment algorithm for chronic anal fissure: a prospective analysis. J Gastrointest Surg. 2005;9:1237-43.

McCallion K, Gardiner KR. Progress in the understanding and treatment of chronic anal fissure. Postgrad Med J. 2001;77:753-8.

Schouten ER, Briel JW, Boerma MO, Auwerda JJA, Wilms EB, Gratsma BH. Pathophysiological aspects and clinical outcome of intra anal application of isosorbide dinitrate in patients with chronic anal fissure. Gut. 1996;39(3):465-9.

Oh C, Divino CM, Steinhaqen RM. Anal fissures 20 years’ experience. Dis Colon Rectum. 1995;38:378-82.

Christie A, Guest JF. Modelling of economic impact of managing a chronic anal fissure, with proprietary formulation of Nitroglycerin (rectogesic) compared to lateral internal sphincterotomy in UK. Int J Colorectal Dis. 2002;17(4):259-67.

Richard CS, Gregoire R, Plewes EA, Silverman R, Burul C, Buie D, et al. Internal sphincterotomy is superior to topical nitroglycerine in the treatment of chronic anal fissure: results of a randomised controlled trial by the Canadian Colorectal Surgical Trials Group. Dis Colon Rectum. 2000;43(8):1048-57.

Mishra BM, Tripathi P, Mishra JM, Debata PK, Panda BK. Comparative study of Glyceryl trinitrate (GTN) ointment versus surgical management of chronic anal fissure. Antiseptic. 2002;99(5):150-3.

Palazzo FF, Kapur S, Steward M, Cullen PT. Glyceryl trinitrate treatment of chronic fissure in ano one year’s experience with 0.5% GTN paste. J R Coll Surg Edinb. 2000;45:168-70.

Oettle GJ. Glyceryl trinitrate versus sphincterotomy for treatment of chronic fissure in ano. Dis Colon Rectum. 1997;40(11):1318-20.

Bacher H, Mischinger HJ, Werkgartner G, Cerwenka H, Shabrawi A, Pteiter J, et al. Local Nitroglycerin for treatment of anal fissure; an alternative to lateral sphincterotomy. Dis Colon Rectum. 1997;40(4):468-70.

Utizg MJ, Kroesen AJ, Buhr HJ. Concepts in pathogenesis and treatment of chronic anal fissure a review of the literature. Am J Gastroenterol. 2003;98(5):968.

Libertiny G, Knight JS, Farout R. Randomised trial of topical 0.2% glyceryl trinitrate and lateral internal sphincterotomy for the treatment of patients with chronic. Eur J Surg. 2002;168(7):418-21.

Tauro LF, Shindhe VV, Aithala PS, Martis JJS, Shenoy HD. Comparative study of Glyceryl Trinitrate ointment versus surgical management of chronic anal fissure. Indian J Surg. 2011;73(4):268-77.