Treatment of chronic anal fissure with topical glyceryl trinitrate

PURPOSE: There has been an emerging trend to treat chronic anal fissures by pharmacologic means. In particular, by the topical application of glyceryl trinitrate. However, such treatment has failed to gain wide acceptance within our local surgical community. The aim of this study was to evaluate the efficacy and patient acceptance of topical glyceryl trinitrate in the management of chronic anal fissures. Methods: A retrospective review was conducted on a consecutive series of 31 patients who were diagnosed as having a chronic anal fissures and were managed by the topical application of 0.2 percent glyceryl trinitrate to the perianal region twice a day. All patients were commenced on a high-fiber diet, and they were reviewed every two weeks until healed or until surgery was required. Patients were subsequently contacted by a mailed questionnaire to determine compliance with therapy, resolution of symptoms, recurrence of symptoms after cessation of therapy, and side effects. RESULTS: Of 31 patients, 27 completed the questionnaire. Only 67 percent (18/27) of patients complied with the treatment as prescribed, and just 56 percent (15/27) achieved complete resolution of their symptoms after three to ten weeks of therapy. Recurrence of symptoms developed in 27 percent (4/15) of these patients after a median follow-up of six months. Side effects were reported in 78 percent (21/27) of patients, and in ten percent (2/21) they were so severe that the patients ceased therapy. CONCLUSION: In this study the treatment of chronic anal fissures with topical glyceryl trinitrate appeared less efficacious than previously reported. In addition, the study highlighted problems with patient compliance, healing rates, and side effects that are associated with this modality therapy.