Published: 2019-03-26

Topical diltiazem versus topical glyceryl trinitrate in the treatment of chronic anal fissure: a prospective comparative study

Venkatesh S., Srinivas B. Kulkarni, Kruthi S. R.


Background: Acute anal fissure (AAF) heals spontaneously with conservative line of treatment. Chronic anal fissure (CAF) needs either traditional surgical lateral sphicterotomy or chemical sphincterotomy with topical agents. The present study aims at the effectiveness of topical diltiazem (DTZ) cream over topical glyceryl trinitrate (GTN) ointment in the treatment of chronic anal fissure.

Methods: A total of 100 patients with CAF were included in this comparative prospective study conducted in Rajarajeswari Medical College and Hospital Bengaluru from July 2017 to December 2018. Eligible patients were randomly assigned to one of the two treatment groups of 50 patients each and were advised to apply 2% DTZ cream or 0.2% GTN ointment by fingertip to the anal verge twice daily for 8 weeks. The results were analysed and compared on two weekly intervals to know the effectiveness of treatment. P value of <0.05 is considered to be significant.

Results: Complete healing of the fissure occurred in 80% of the patients in DTZ group against 76% in the GTN group by the end of 6 weeks (p>0.05, statistically not significant). Mild headache was experienced by 14% of the patients in the DTZ group, while 46% of the cases in the GTN group reported about the same (p<0.05 statistically significant).

Conclusions: Topical 2% DTZ appeared to be well tolerated and effective preferred first-line method of chemical sphincterotomy with less side effects for chronic anal fissure.


Anal fissure, Acute anal fissure, Chronic anal fissure, Chemical sphincterotomy, Glyceryl trinitrate, Diltiazem hydrochloride

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Knight JS, Birks M, Farouk R. Topical diltiazem ointment in the treatment of chronic anal fissure. Br J Surg. 2001;88(4):553-6.

Pravin Gupta J. The treatment of fissure in ano- revisited. Afr Health Sci. 2004;4(1):58–62.

Cross KLR, Massey EJD, Fowler AL and Monson JRT. The management of anal fissure: ACPGBI Position Statement, Colorectal Dis. 2008;10:1-7.

Lock MR, Thompson JPS. Fissure-in-ano: the initial management and prognosis. Br J Surg. 1977;64:355-8.

Leong AP. Pharmacological treatment of anal fissure – a future role in primary care. Singapore Med J. 2003;44:136-7.

Carapeti EA, Kamm MA, Phillips RK. Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side-effects. Dis Colon Rectum. 2000;43:1359-62.

Garcia-Aguilar J, Belmonte Montes C, Perez JJ, Jensen L, Madoff RD, Wong WD. Incontinence after lateral internal sphincterotomy: anatomical and functional evaluation. Dis Colon Rectum. 1998;41:423-7.

Nelson R. A systematic review of medical therapy for anal fissure. Dis Colon Rectum. 2004;47:422-31.

Dasgupta R, Franklin I, Pitt J, Dawson PM. The successful treatment of chronic anal fissures with the diltiazem gel. Colorect Dis. 2002;4:20–2.

Hyman NH, Cataldo PA. Nitroglycerin ointment for anal fissures: effective treatment or just a headache? Dis Colon Rectum. 1999;42:383-5.

Shrivastava UK, Jain BK, Kumar P, Saifee Y. A comparison of the effects of diltiazem and glyceryl trinitrate ointment in the treatment of chronic anal fissure: a randomized clinical trial. Surg Today. 2007;37:482-5.

Sadaf AU, Manzar S. Effectiveness of topical diltiazem versus glyceryl trinitrate in the treatment of chronic anal fissures. Pak J Surg. 2003;19:62-7.

Kocher HM, Steward M, Leather AJM, Cullen PT. Randomized clinical trial assessing the side-effects of glyceryl trinitrate and diltiazem hydrochloride in the treatment of chronic anal fissure. Br J Surg. 2002;89:413-7.

Bielecki K, Kolodziejczak M. A prospective randomized trial of diltiazem and glyceryl trinitrate ointment in the treatment of chronic anal fissure. Colorectal Dis. 2003;5:256-7.

Lindsey I, Jones OM, Cunningham C, Mortensen NJ. Chronic anal fissure. Br J Surg. 2004;91:270-9.

Altomare DF, Rinaldi M, Milito G, Arcana F, Spinelli F, Nardelli N, et al. Glyceryl trinitrate for chronic anal fissure – healing or headache? Results of a multicenter, randomized, placebocontroled, double blind trial. Dis Colon Rectum. 2000;43:174 9.

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

Griffin N, Acheson AG, Jonas M, Scholefield JH. The role of topical diltiazem in the treatment of chronic anal fissures that have failed glyceryl trinitrate therapy. Colorectal Dis. 2002;4:430-5.

Jonas M, Speake W, Scholefield JH. Diltiazem heals glyceryl trinitrate-resistant chronic anal fissures: a prospective study. Dis Colon Rectum. 2002;45:1091-5.