Nitroglycerine: A Paradigm in Treatment of Chronic Anal Fissure

Background/ Aims: Anal fissure is a common problem that causes significant morbidity in a young population. Surgical techniques like manual anal dilatation or lateral internal sphincterotomy, effectively heals most fissures but may result in anal continence. ‘Chemical Sphincterotomy' is thus investigated and used as the possible first line treatment for anal fissures. The present study is designed to evaluate the role of topical Nitroglycerine ointment in cases of chronic anal fissures. Methods: A prospective observational study was conducted at a tertiary healthcare centre. A total of 90 patients of chronic anal fissure were included in the study. Nitroglycerine ointment (0.2%) application was advised to all patients (thrice daily). Lateral internal sphincterotomy was performed where medical management failed or in cases with severe pain. Follow up was maintained for a period of 6 weeks or until fissure is healed. Results: Out of the total 90 cases, 34 (37.7%) cases responded to Nitroglycerine ointment while 56 (62.3%) required lateral internal sphincterotomy. The relief of pain was faster with sphincterotomy than with Nitroglycerine, as observed by comparing mean pain score at the end of 6 weeks (0.51 vs 1.33; p<0.01). Wound infection rate for sphincterotomy was 3.6%. Conclusion: Nitroglycerine ointment is effective in about a third of the chronic anal fissures cases. Thus it should be advocated as the first option of treatment for chronic cases and sphincterotomy should be reserved for patients with therapeutic failure of pharmacological treatment and those with severe pain.