Diseases of the Colon & Rectum

, Volume 40, Issue 4, pp 468–470 | Cite as

Glyceryl trinitrate is an effective treatment for anal fissure

  • J. N. Lund
  • J. H. Scholefield
Original Contributions


PURPOSE: It has been suggested that chronic anal fissure is ischemic in origin because of poor blood supply and spasm of the internal anal sphincter. Nitric oxide donors such as glyceryl trinitrate (GTN) cause a chemical sphincterotomy leading to healing of the fissure. This study addresses the hypothesis that topical GTN ointment may be an effective nonsurgical treatment for chronic anal fissure. METHODS: Thirty-nine consecutive patients (23 women; median age, 34 (range, 16–54) years) with chronic anal fissure presenting to the surgical outpatient department were treated for four to six weeks with 0.2 percent GTN ointment applied twice daily to the anoderm. Maximum anal resting pressure was measured at steady state before and after application of the ointment at the first visit. Patients were assessed at two weekly intervals. RESULTS: Previous surgery for fissure had been performed in seven patients. There were 30 posterior and 9 anterior fissures. Resting maximum anal resting pressure fell from 122.1 ± 44 to 72.5 ± 33.3 cm of water (mean ± standard deviation) by 20 minutes after application of ointment (P <0.0001; pairedt-test). Healing was complete in 14 patients at four weeks and in 33 patients at six weeks. Fissures recurred in five patients after treatment had been stopped. Four recurrences were successfully treated by further GTN ointment and one by sphincterotomy. CONCLUSIONS: This study shows that most anal fissures can be treated nonsurgically with topically applied 0.2 percent GTN ointment. Prospective, randomized controlled trials are now needed, because nonsurgical treatment of anal fissure avoids permanent division of part of the sphincter and the consequent disturbance of continence mechanisms.

Key words

Anal fissure Sphincterotomy Nitric oxide 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Lock MR, Thomson JP. Fissure-in-ano: the initial management and prognosis. Br J Surg 1977;64:355–8.Google Scholar
  2. 2.
    McDonald P, Driscoll AM, Nicholls RJ. The anal dilator in the conservative management of acute anal fissures. Br J Surg 1983;70:25–6.PubMedGoogle Scholar
  3. 3.
    Keighley M, Williams N. Surgery of the anus, rectum and colon. 1st ed. London: WB Saunders, 1993.Google Scholar
  4. 4.
    Gibbons CP, Read NW. Anal hypertonia in fissures: cause or effect? Br J Surg 1986;73:443–5.PubMedGoogle Scholar
  5. 5.
    Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum 1989;32:43–52.PubMedGoogle Scholar
  6. 6.
    Schouten WR, Briel JW, Auwerda JJ, De Graff EJ. Ischaemic nature of anal fisure. Br J Surg 1996;83:63–5.Google Scholar
  7. 7.
    Abcarian H. Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy vs. fissurectomymidline sphincterotomy. Dis Colon Rectum 1980;23:31–6.PubMedGoogle Scholar
  8. 8.
    Milito G, Arullani A, Brancaleone C, Cesca D, Filingeri V, Casciani CU. Subcutaneous lateral internal sphincterotomy in the treatment of chronic anal fissure. Ital J Surg Sci1983;13:275–9.PubMedGoogle Scholar
  9. 9.
    Khubchandani IT, Reed JF. Sequelae of internal sphincterotomy for chronic fissure in ano. Br J Surg 1989;76:431–4.PubMedGoogle Scholar
  10. 10.
    Sultan AH, Kamm MA, Nicholls RJ, Bartram CI. Prospective study of the extent of internal anal sphincter division during lateral sphincterotomy. Dis Colon Rectum 1994;37:1031–3.Google Scholar
  11. 11.
    O'Kelly TJ. Nerves that say NO: a new perspective on the human rectoanal inhibitory reflex. Ann R Coll Surg Engl 1995;78:31–8.Google Scholar
  12. 12.
    Fung H-L. Clinical pharmacology of organic nitrates. Am J Cardiol 1993;72:9C-15C.CrossRefPubMedGoogle Scholar
  13. 13.
    Loder PB, Kamm MA, Nicholls RJ, Phillips RK. ‘Reversible chemical sphincterotomy’ by local aplication of glyceryl trinitrate. Br J Surg 1994;81:1386–9.PubMedGoogle Scholar
  14. 14.
    Gorfine SR. Treatment of benign anal disease with topical nitroglycerin. Dis Colon Rectum 1995;38:453–6, Discussion on: Dis Colon Rectum 1995;38:456–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Gorfine S. Topical nitroglycerine therapy for anal fissures and ulcers. N Engl J Med 1995;333:1156–7.CrossRefPubMedGoogle Scholar

Copyright information

© American Society of Colon and Rectal Surgeons 1997

Authors and Affiliations

  • J. N. Lund
    • 1
  • J. H. Scholefield
    • 1
  1. 1.Department of Surgery, E Floor, West BlockUniversity HospitalNottinghamUK

Personalised recommendations