Comparative Study of Glyceryl Trinitrate Ointment Versus Surgical Management of Chronic Anal Fissure

Abstract

Chronic Anal Fissure (CAF) is common perineal condition and well-known painful entity. Standard surgical treatment even though available, may require long hospital stay and sometimes have worrying complications like anal incontinence. So non-surgical treatment, Glyceryl Trinitrate has been shown to be an effective for chronic anal fissure. It decreases anal tone and ultimately heals the anal fissure. The present study is the attempt to know the efficacy of 0.2% Glyceryl Trinitrate ointment in the treatment of chronic anal fissure and to compare the effectiveness of 0.2% Glyceryl Trinitrate ointment (GTN) versus fissurectomy with lateral internal sphincterotomy (LIS) and fissurectomy with posterior internal sphincterotomy (PIS) in the management of chronic anal fissure. This is a prospective comparative study of management of chronic anal fissure done in our hospital during the period of one and half year from October 2005 to March 2007. Thirty patients treated with 0.2% Glyceryl Trinitrate ointment and 30 patients treated with fissurectomy and lateral internal sphincterotomy and 30 patients treated with posterior internal sphincterotomy, for chronic anal fissure were selected for study. A single brand of 0.2% Glyceryl Trinitrate ointment (Nitrogesic) used for trial arm. Dose of administration was 1.5 cm to 2 cm in the anal canal with device provided by manufacturers of the proprietary preparation and applied twice a daily for 12 weeks. Patients were followed up for 12 weeks and thereafter evaluated for relief of symptoms in all three groups. Observations were recorded at 2 weeks; 6 weeks and 12 weeks of follow up period, regarding symptoms like pain and bleeding during defecation, healing of CAF and also for side effects like headache in GTN group and flatus, fecal incontinence in surgical groups. Data collected in proforma and analyzed. Study revealed CAF was more in male 59 patients (66%) than the female 31 patients (34%), the ratio being 1: 0.52. The maximum number of patients was encountered in the age group of 20 to 40 years with mean duration of age 34.14 years. In all three groups symptoms like pain, bleeding, constipation and sphincter spasm were present. Sentinel pile was present in 56% of the patients. Common site of fissure was found to be posterior in 94% of patients. Observations with respect to relief of pain, no bleeding and healing were recorded at 2, 6 and 12 weeks of duration. Lateral sphincterotomy remains effective but should be reserved for the patients who fail to respond to initial chemical sphincterotomy or GTN therapy. GTN is good alternative mode of therapy for patients who refuse surgery and prefer medical line of treatment.

Study of Operated Patients of Lateral Internal Anal Sphincterotomy for Chronic Anal Fissure

“…Age group in most studies were between 31 to 40 years [6][7][8][9]. Most of the patients were from younger age group in present study which might be due to changing habits of low fiber diet in young age group leading to constipation and subsequent anal fissure.…”

“…Study done by Tauro LF et al, had shown incidence of flatus incontinence of 3.3% and anal seepage of 6.6% in lateral sphincterotomy group [8]. 'Study of "tailored" lateral sphincterotomy by selecting the height of sphincter to be divided' done by David RG Littlejohn et al had shown that incidence of imperfect control of flatus of 1.4%, minor staining of 0.35 % and urgency of 0.7 %, which is less compared to our study [11].…”

“…Study done by Shafiq ullah et al, [6] and other study done by Tauro LF et al, had shown more male patients than female [8]. Study done by Oh C et al, had shown equal ratio of male and female [7].…”

Natural Treatments for Fissure in Ano Used by Traditional Persian Scholars, Razi (Rhazes) and Ibn Sina (Avicenna)

“…5 Fissures often recur after medical therapy. 6 On the other hand, surgical treatment of chronic anal fissure is associated with complications such as ecchymosis, hematoma, 7 pain, postsurgical secondary infection, 8 abscess and fistula formation, 9 long hospital stay, 10 and a degree of incontinence, which has been reported to be in up to 30% of patients. 11 Nowadays, the use of nonsurgical method as the first-line treatment of chronic anal fissure is well accepted.…”

“…Because of possibility of failure and complications after surgery, research for the nonsurgical treatment of chronic fissure continues. 10 Complementary and alternative medicine is a branch of medicine based on the holistic concept of health that can improve the quality of life along with the treatment of the ailment. 12 The philosophy behind complementary and alternative medicine is different from that of Western medicine.…”