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A systematic review of medical therapy for anal fissure

  • Original Contributions
  • Diseases of the Colon & Rectum
  • Published:
Diseases of the Colon & Rectum

Abstract

Purpose: This is a meta-analysis of randomized, controlled trials to assess the efficacy and morbidity of medical therapies for anal fissure. Methods: Medline and the Cochrane Controlled Trials Register and the Cochrane Colorectal Cancer Review Groups Controlled Trials Register were searched using the terms “anal fissure randomized” from 1966 to 2002. Studies in which participants were randomized to a nonsurgical therapy for anal fissure were the focus of this review. Comparison groups included an operative procedure, an alternate medical therapy, or placebo. Chronic fissure, acute fissure, and fissure in children were included in the review, however, atypical fissure associated with inflammatory bowel disease, cancer, or anal infection were excluded. Data were abstracted from published reports and meeting abstracts, assessing method of randomization, blinding, “intention to treat” and dropouts, therapies, supportive measures, dosing and frequency, and crossovers. Outcome measures included nonhealing of the fissure and adverse events. Results: Twenty one different comparisons of medical therapies to heal anal fissure have been reported in 31 trials, including 9 agents—glyceryl trinitrate, isosorbide dinitrate, botulinum toxin, diltiazem, nifedipine, hydrocortisone, lidocaine, bran, placebo—as well as anal dilators and surgical sphincterotomy. Glyceryl trinitrate was favored in the analysis over placebo (odds ratio =0.55, 95 percent confidence interval, 0.41–0.74). After excluding two studies from analysis because of placebo response rates < 2 standard deviations below the mean for all studies, the advantage of glyceryl trinitrate over placebo was no longer statistically significant (odds ratio = 0.78; 95 percent confidence interval, 0.56–1.08). Nifedipine and diltiazem did not differ from glyceryl trinitrate in their ability to cure fissure (0.66; 0.22–2.01). Botulinum toxin compared with placebo showed no significant efficacy (0.75; 0.32–1.77), and was also no better than glyceryl trinitrate (0.48; 0.21–1.10). Surgery was more effective than medical therapy in curing fissure (0.12; 0.07–0.22). Conclusions: Medical therapy for chronic anal fissure, acute fissure, and fissure in children may be applied with a chance of cure that is only marginally better than placebo, and for chronic fissure, far less effective than surgery.

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References

  1. Goligher JC, Surgery of the anus, rectum & colon, 3rded. London, Balliere & Tindall, 1975

    Google Scholar 

  2. Schouten WR, Briel JW, Auwerda JJ. Relationship between anal pressure and anodermal blood flow: the vascular pathogeneisis of anal fissures. Dis Colon Rectum 1994;37:664–9

    Article  PubMed  CAS  Google Scholar 

  3. Abcarian H. Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy vs. fissurectomy-midline sphincterotomy. Dis Colon Rectum 1980; 23:31–6

    Article  PubMed  CAS  Google Scholar 

  4. Garcia-Aguilar J, Belmonte C, Wong D, Lowry AC, Mad-off RD. Open vs Closed sphincterotomy for chronic anal fissure: long term results. Dis Colon Rectum 1996;39: 440–3

    Article  PubMed  CAS  Google Scholar 

  5. Nelson RL. Outcome of operative procedures for fissure in ano. Cochrane Library. 2003. #4

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

    Article  PubMed  CAS  Google Scholar 

  7. Antropoli C, Perrotti P, Rubino M, et al. Nifedipine for local use in conservative treatment of anal fissures: preliminary results of a multicenter study. Dis Colon Rectum 1999;42:1011–5

    Article  PubMed  CAS  Google Scholar 

  8. Bacher H, Mischinger HJ, Werkgartner G, et al. Local nitroglycerin for treatment of anal fissures: an alternative to lateral sphincterotomy? Dis Colon Rectum 1997; 40:840–5

    Article  PubMed  CAS  Google Scholar 

  9. Bailey HR, Beck DE, Billingham RP, et al. A study to determine the nitroglycerin ointment dose and dosing interval that best promote the healing of chronic anal fissures. Dis Colon Rectum 2002;45:1192–9

    Article  PubMed  Google Scholar 

  10. Bassotti G, Clementi M, Ceccarelli F, Pelli M. Double blind manometric assessment of two topical glyceral trinitrate formulations in patients with chronic anal fissures. Digest Liver Dis 2000;32:699–702

    Article  CAS  Google Scholar 

  11. Brisinda G, Maria G, Bentivoglio AR, Cassetta E, Gui D, Albanese A. A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. N Engl J Med 1999;34l: 65–9

    Article  Google Scholar 

  12. Brisinda G, Maria G, Sganga G, Bentivoglio AR, Albanese A, Castagneto M. Effectiveness of higher doses of botulinum toxin to induce healing in patient with chronic anal fissures. Surgery 2002;131:179–84

    Article  PubMed  Google Scholar 

  13. Carapeti EA, Kamm MA, McDonald PJ, Chadwick LS, Melville D, Phillips RK. Randomized controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective and there is a high recurrence rate. Gut 1999;44:727–30

    Article  PubMed  CAS  Google Scholar 

  14. Chaudhuri S, Pal AK, Acharya A, et al. Treatment of chronic anal fissure with topical glyceryl trinitrate: a double blind, placebo controlled trial. Indian J Gastroenterol 2001;20:101–2

    PubMed  CAS  Google Scholar 

  15. Evans J, Luck A, Hewett P. Glyceryl trinitrate vs. lateral sphincterotomy for chronic anal fissure: a prospective, randomized trial [Meeting Abstract]. Dis Colon Rectum 2001;44:93–7

    Article  PubMed  CAS  Google Scholar 

  16. Gecim I. Comparison of glyceryl trinitrate and botulinum toxin A in treatment of chronic anal fissure: a prospective, randomized study. Dis Colon Rectum 2001;44: A20–1

    Article  Google Scholar 

  17. Gough MJ, Lewis A. The conservative treatment of fissure in ano. Br J Surg 1983;70:175–6

    Article  PubMed  CAS  Google Scholar 

  18. Jensen SL. Treatment of first episodes of acute anal fissure: prospective randomized study of lignocaine ointment versus hydrocortisone ointment or warm sitz baths plus bran. BMJ 1986;292:1167–70

    Article  PubMed  CAS  Google Scholar 

  19. Jensen SL. Maintenance therapy with unprocessed bran in the prevention of acute anal fissure recurrence. J R Soc Med 1987;80:296–8

    PubMed  CAS  Google Scholar 

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

    Article  PubMed  CAS  Google Scholar 

  21. Kennedy ML, Sowter S, Nguyen H, Lubowski DZ. Glyceryl trinitrate ointment for the treatment of chronic anal fissure: results of a placebo-controlled trial and longterm follow-up. Dis Colon Rectum 1999;42:1000–6

    Article  PubMed  CAS  Google Scholar 

  22. Kenny SE, Irvine T, Driver CP, et al. Double blind randomized controlled trial of topical glyceryl trinitrate in anal fissure. Arch Dis Childhood 2001;85:404–7

    Article  CAS  Google Scholar 

  23. 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;89:4l3–7

    Article  Google Scholar 

  24. Libertiny G, Knight JS, Farouk R. Randomized trial of topical 0.2% glyceryl trinitrate and lateral internal sphincterotomy for the treatment of patients with chronic anal fissures: long term follow-up. Eur J Surg 2002;l68:4l8–21

    Google Scholar 

  25. Lund JN, Scholefield JH. A randomized, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate in treatment of anal fissure. Lancet 1997;349: 11–4

    Article  PubMed  CAS  Google Scholar 

  26. 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

    Article  PubMed  CAS  Google Scholar 

  27. MacDonald P, Driscoll AM, Nicholls RJ. The anal dilator in the conservative management of acute anal fissure. Br J Surg 1983;70:25–6

    Article  Google Scholar 

  28. Mentes BB, Irkorucu O, Akin M, Leventoglu S, Tatlicio-glu E. Comparison of botulinum toxin injection and lateral internal sphincterotomy in the treatment of chronic anal fissure. Dis Colon Rectum 2003;46:232–7

    Article  PubMed  Google Scholar 

  29. Oettle GJ. Glyceryl trinitrate vs. sphincterotomy for treatment of chronic fissure-in-ano: a randomized, controlled trial. Dis Colon Rectum 1997;40:1318–20

    Article  PubMed  CAS  Google Scholar 

  30. Oglesby S, Wilson-Storey D, Munro F. A placebo controlled randomized trial of 0.2% GTN in the treatment of chronic anal fissures in children [abstract]. Digestive Disease Week. 2001.

  31. Perrotti P, Bove A, Antropoli C, et al. Topical nifedipine with lidocaine vs. active control for the treatment of chronic anal fissure: results of a prospective, randomized, double-blind study. Dis Colon Rectum 2002 ;45: 1468–75

    Article  PubMed  Google Scholar 

  32. Richard CS, Gregroire R, Plewes EA, 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

    Article  PubMed  CAS  Google Scholar 

  33. Siprooudhis L, Sebille V, Pigot F, Hemerey P, Juguet F, Bellisant E. Lack of efficacy of botulinum toxin in chronic anal fissure. Aliment Pharmacol Thera 2003;18: 515–24

    Article  Google Scholar 

  34. Sonmez K, Demmirogullan B, Ekingen G, et al. Randomized Placebo controlled treatment of anal fissure by lidocaine, EMLA and GTN in children. J Pediatr Surg 2002;37:1313–6

    Article  PubMed  Google Scholar 

  35. Tander B, Guven A, Demirbag S, Ozkan Y, Ozturk H, Cetinkursun S. A prospective, randomized, doubleblind, placebo-controlled trial of glyceryl trinitrate ointment in the treatment of children with anal fissure. J Pediatr Surg 1999;34:1810–2

    Article  PubMed  CAS  Google Scholar 

  36. Werre AJ, Palamba HW, Bilgen EJS, Eggink WF. Isosorbide dinitrate in the treatment of anal fissure: a randomized, prospective double blind placebo controlled trial. Eur J Surg 2001;l67:382–5

    Google Scholar 

  37. Zuberi BF, Rajput MR, Abro H, Shaikh SA. A randomized trial of glyceryl trinitrate ointment and nitroglycerin patch in healing of anal fissures. Int J Colorectal Dis 2000;15:243–5

    Article  PubMed  CAS  Google Scholar 

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  1. Department of Surgery, University of Illinois College of Medicine at Chicago, 1740 West Taylor Street, m/c 957, 60612, Chicago, Illinois

    Richard Nelson

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Correspondence to Richard Nelson.

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Nelson, R. A systematic review of medical therapy for anal fissure. Dis Colon Rectum 47, 422–431 (2004). https://doi.org/10.1007/s10350-003-0079-5

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