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Manometric Study of Topical Sildenafil (Viagra®) in Patients With Chronic Anal Fissure: Sildenafil Reduces Anal Resting Tone

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Diseases of the Colon & Rectum

PURPOSE:

Topical therapies for anal fissure have largely focused on nitric-oxide donors (e.g., nitroglycerin), sometimes with undesirable side effects or inconsistent benefits. Topical phosphodiesterase inhibitors have theoretical merit but have never been reported in treatment of anal fissure. This article describes manometric analysis of the effects of a phosphodiesterase-5 inhibitor, topical sildenafil (Viagra®) in 19 consecutive patients with chronic anal fissure with no previous treatment history.

METHODS:

Station pullthrough manometry was performed with patients in the left-lateral position. Maximum resting pressure (MRP1) was recorded, and 0.75 ml of 10 percent sildenafil was then instilled in the anal canal. Maximum resting pressure was repeated at the same distance from the anal verge. Thereafter, pressure was measured continuously. Time for initial relaxation (T1) and time to maximal relaxation (T2) were recorded. Average resting pressure (MRP2) was calculated. Results were analyzed by Student’s t-test.

RESULTS:

Topical administration of 10 percent sildenafil was accompanied by significant reduction in anal sphincter pressure (18 percent; P < 0.01). Only one patient failed to respond. Average onset of action was less than three minutes, with maximum effect one minute later. MRP1: 119.3 ± 18.7 cmH2O. MRP2: 97.8 ± 21.3 cmH2O. MRP2 < MRP1, P < 0.01. MRP M vs. F, ns. T1: 168 ± 67 seconds (M = 210 ± 72, F = 130 ± 53, P < 0.02). T2: 230 ± 78 seconds (M = 271 ± 63, F = 183 ± 75, P < 0.02). Mild-to-moderate anal discomfort was reported by 26 percent of patients. No headaches or other side effects were reported.

CONCLUSIONS:

Topical administration of a phosphodiesterase-5 inhibitor (sildenafil, Viagra®) significantly reduces anal sphincter pressure in patients with chronic anal fissure. A beneficial effect of nitric oxide on the spastic anal sphincter has been demonstrated previously. This study confirms that this effect need not be derived solely from nitric oxide donors. New therapeutic avenues for treatment of anal fissure through indirect enhancement of nitric oxide activity are suggested.

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References

  1. BD Hancock (1977) ArticleTitleThe internal sphincter and anal fissure Br J Surg 64 92–5

    Google Scholar 

  2. G Dodi F Bogoni A Infantino P Pianon LM Mortellaro M Lise (1986) ArticleTitleHot or cold in anal pain? A study in changes in internal sphincter pressure profiles Dis Colon Rectum 29 248–51

    Google Scholar 

  3. JN Lund JH Scholefield (1996) ArticleTitleAetiology and treatment of anal fissure Br J Surg 83 1335–44

    Google Scholar 

  4. WR Schouten JD Blankensteijn (1992) ArticleTitleUltra slow wave pressure variations in the anal canal before and after lateral internal sphincterotomy Int J Colorect Dis 7 115–8

    Google Scholar 

  5. R Farouk GS Duthie AB MacGregor DC Bartolo (1994) ArticleTitleSustained internal sphincter hypertonia in patients with chronic anal fissure Dis Colon Rectum 37 424–9

    Google Scholar 

  6. CP Gibbons NW Read (1986) ArticleTitleAnal hypertonia in anal fissures: cause or effect? Br J Surg 73 443–5

    Google Scholar 

  7. JF Stebbing (1998) ArticleTitleNitric oxide synthase neurones and neuromuscular behaviour of the anorectum Ann R Coll Surg Engl 80 137–45

    Google Scholar 

  8. JF Stebbing AF Brading NJ Mortensen (1997) ArticleTitleRole of nitric oxide in relaxation of the longitudinal layer of rectal smooth muscle Dis Colon Rectum 40 706–10

    Google Scholar 

  9. JF Stebbing AF Brading NJ Mortensen (1996) ArticleTitleNitric oxide and the rectoanal inhibitory reflex: retrograde neuronal tracing reveals a descending nitrergic rectoanal pathway in a guinea-pig model Br J Surg 83 493–8

    Google Scholar 

  10. TJ O’Kelly AF Brading NJ Mortensen (1993) ArticleTitleNerve mediated relaxation of the human internal anal sphincter: the role of nitric oxide Gut 34 689–93

    Google Scholar 

  11. RM Palmer AG Ferrige S Moncada (1987) ArticleTitleNitric oxide release accounts for the biological activity of endothelium-derived relaxing factor Nature 327 524–6

    Google Scholar 

  12. S Rattan A Sarkar S Chakder (1992) ArticleTitleNitric oxide pathway in rectoanal inhibitory reflex of opossum internal anal sphincter Gastroenterology 103 43–50

    Google Scholar 

  13. OM Jones NJ Mortensen (2002) ArticleTitlePhosphodiesterase inhibitors cause relaxation of the internal anal sphincter in vitro Dis Colon Rectum 45 530–6

    Google Scholar 

  14. C Oh CM Divino RM Steinhager (1995) ArticleTitleAnal fissure: 20-year experience Dis Colon Rectum 38 378–82

    Google Scholar 

  15. U Usatoff AL Polglase (1995) ArticleTitleThe longer term results of internal anal sphincterotomy for anal fissure ANZ 65 576–8

    Google Scholar 

  16. WR Schouten JW Briel JJ Auwerda (1994) ArticleTitleRelationship between anal pressure and anodermal blood flow: the vascular pathogenesis of anal fissures Dis Colon Rectum 37 664–9

    Google Scholar 

  17. N Hananel PH Gordon (1997) ArticleTitleLateral internal sphincterotomy for fissure-in-ano revisited Dis Colon Rectum 40 597–602

    Google Scholar 

  18. IT Khubchandani JF Reed (1989) ArticleTitleSequelae of internal sphincterotomy for chronic fissure in ano Br J Surg 76 431–4

    Google Scholar 

  19. AP Zbar M Beer-Gabel AC Chiappa M Aslam (2001) ArticleTitleIncontinence of the minor anorectal surgery Dis Colon Rectum 44 1610–23

    Google Scholar 

  20. J Garcia-Aguilar CB Montes JJ Perez L Jensen RD Madoff WD Wong (1998) ArticleTitleIncontinence after lateral internal sphincterotomy: anatomic and functional evaluation Dis Colon Rectum 41 423–7

    Google Scholar 

  21. J Garcia-Aguilar C Belmonte WD Wong AC Lowry RD Madoff (1996) ArticleTitleOpen vs. closed sphincterotomy for chronic anal fissure: long-term results Dis Colon Rectum 39 440–3

    Google Scholar 

  22. AH Sultan MA Kamm RJ Nicholls CI Bartram (1994) ArticleTitleProspective study of the extent of internal anal sphincter division during lateral sphincterotomy Dis Colon Rectum 37 1031–3

    Google Scholar 

  23. DR Littlejohn GL Newstead (1997) ArticleTitleTailored lateral sphincterotomy for anal fissure Dis Colon Rectum 40 1439–42

    Google Scholar 

  24. E Xynos A Tzortzinis E Chrysos G Tzovaras JS Vassilakis (1993) ArticleTitleAnal manometry in patients with fissure-in-ano before and after internal sphincterotomy Int J Colorect Dis 8 125–8

    Google Scholar 

  25. BJ Pernikoff TE Eisenstat RJ Rubin GC Oliver EP Salvati (1994) ArticleTitleReappraisal of partial lateral internal sphincterotomy Dis Colon Rectum 37 1291–5

    Google Scholar 

  26. SL Jensen (1987) ArticleTitleMaintenance therapy with unprocessed bran in the prevention of acute anal fissure recurrence J R Soc Med 80 296–8

    Google Scholar 

  27. D Vouillamoz (1996) ArticleTitleAnal fissure. Conservative treatment Swiss Surg 1 18–20

    Google Scholar 

  28. PB Loder MA Kamm RJ Nicholls RK Phillips (1994) ArticleTitleReversible chemical sphincterotomy by topical application of glyceryl trinitrate Br J Surg 81 1386–9

    Google Scholar 

  29. SR Gorfine (1995) ArticleTitleTreatment of benign anal disease with topical nitroglycerin Dis Colon Rectum 38 453–7

    Google Scholar 

  30. R Madoff (1998) ArticleTitlePharmacological therapy for anal fissure N Engl J Med 338 257–9

    Google Scholar 

  31. J Lund J Scholefield (1997) ArticleTitleA randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure Lancet 349 11–4

    Google Scholar 

  32. EA Carapeti MA Kamm PJ Donald ParticleMc SJ Chadwick D Melville RK Phillips (1999) ArticleTitleRandomised controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate Gut 44 727–30

    Google Scholar 

  33. GJ Oettle (1995) ArticleTitleGlyceryl trinitrate vs. sphincterotomy for treatment of chronic fissure-in-ano: a randomized, controlled trial Dis Colon Rectum 38 453–7

    Google Scholar 

  34. DF Altmore M Rinaldi G Miltito (2000) ArticleTitleGlyceryl trinitrate for chronic anal fissure-healing or headache Dis Colon Rectum 43 174–81

    Google Scholar 

  35. G Salgado L Torrabadella I Berman (1999) ArticleTitleHeadaches in the treatment of anal fissure Dis Colon Rectum 42 1106

    Google Scholar 

  36. N Griffin DD Zimmerman JW Briel et al. (2002) ArticleTitleTopical l-arginine gel lowers anal resting pressure: possible treatment for anal fissure Dis Colon Rectum 45 1332–6

    Google Scholar 

  37. EA Carapeti MA Kamm BK Evans RK Phillips (1999) ArticleTitleTopical diltiazem and bethanechol decrease anal sphincter pressure without side effects Gut 45 719–22

    Google Scholar 

  38. C Antropoli P Perroti M Rubino et al. (1999) ArticleTitleNifedipine for local use in conservative treatment of anal fissures: preliminary results of a multicenter study Dis Colon Rectum 42 1011–5

    Google Scholar 

  39. EA Carapeti MA Kamm RK Phillips (1998) ArticleTitleDiltiazem lowers resting anal sphincter pressure. A potential low side-effect alternative to glyceryl trinitrate for fissures Gut 42 A97

    Google Scholar 

Download references

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Authors and Affiliations

  1. Hospital Europa-USP, Marbella, Spain

    Luis Torrabadella M.D., Gervasio Salgado M.D. & Ray W. Burns D.Ph.

  2. Southeast Georgia Regional Medical Center, Brunswick, Georgia

    Irwin R. Berman M.D.

Authors
  1. Luis Torrabadella M.D.
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  2. Gervasio Salgado M.D.
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  3. Ray W. Burns D.Ph.
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  4. Irwin R. Berman M.D.
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Correspondence to Gervasio Salgado M.D..

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Torrabadella, L., Salgado, G., Burns, R. et al. Manometric Study of Topical Sildenafil (Viagra®) in Patients With Chronic Anal Fissure: Sildenafil Reduces Anal Resting Tone. Dis Colon Rectum 47, 733–738 (2004). https://doi.org/10.1007/s10350-003-0110-x

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  • DOI: https://doi.org/10.1007/s10350-003-0110-x

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