ANORECTAL DISORDERS

To evaluate the clinical efficacy and safety of glyceryl trinitrate (GTN) ointment in the treatment of anal fissure. In this multi-center, randomized, double-blind and placebo-controlled trial, 240 chronic anal fissure patients from 7 clinical centers were randomized to receive eight-week treatment with GTN ointment (treatment group) or vaseline ointment (control group) respectively. Healing rate, visual analogue score (VAS), maximum anal resting pressure (MARP) and adverse reactions were recorded and compared. A total of 221 patients (92.1%) finished the trial, including 114 patients in treatment group (95.0%, 114/120) and 107 in control group (89.2%, 107/120). At the endpoint of treatment (56 d), 90 patients in treatment group (78.9%, 90/114) healed completely compared to 31 patients in control group (29.0%, 31/107), and decrease rates of VAS in the two groups were (94.8±15.7)% and (61.2±35.7)% respectively, both differences were statistically significant (P<0.01). MARP after first administration was (20.2±18.5) mm Hg in treatment group (n=12) and (7.1±14.7) mm Hg in control group (n=6), which was not significantly different (P=0.152). Adverse reaction incidence was higher in treatment group (42.1% vs. 9.3%, P<0.05), while these adverse reactions were mainly headache and fullness in head, which were self-limiting. GTN ointment can effectively promote healing and relieve pain in anal fissure with safety and tolerance.

An anal fissure is a common condition that affects patients of all ages. Its clinical presentation is a sharp pain on defecation with or without blood. It is treated by conservative or surgical means. This study aims to assess the efficacy of a sitz bath as compared to lateral internal sphincterotomy in the treatment of anal fissures. The search strategy used keywords related to the topic of study. Three databases were used: PubMed, Google Scholar, and Science Direct. A total of 551 articles were screened. A quality assessment check was done on the articles leaving 11 articles. Four aspects of sitz bath outcomes were evaluated in the articles. In terms of analgesia, articles showed conflicting evidence. However, the overall evidence supports the use of sitz baths for their analgesic properties. In terms of healing, most articles had similar recovery rates of around 80%. Much of the research supported the use of sitz baths as the primary treatment to heal acute fissures. When compared to lateral internal sphincterotomy, the recovery rates of lateral internal sphincterotomy are superior to those of conservative treatment, including sitz baths. However, studies showed incontinence as a side effect of lateral internal sphincterotomy, and no studies reported side effects from the sitz baths. To conclude, the results of the articles support the use of sitz baths to treat anal fissures. Sitz baths have been found to have analgesic properties, as well as a good healing time. But, compared to lateral internal sphincterotomy, there is a significant difference in the healing rate at the end stage of treatment, lateral internal sphincterotomy is found to be superior. With regards to the side effects, none have been reported from using a sitz bath.

Current therapeutic guidelines for the treatment of chronic anal fissure establish a medical approach as the first step. Glyceryl trinitrate ointment is the most popular of the available topical treatments in Spain but it is associated with the appearance of headache. The purpose of this study was to compare the compliance rate among patients receiving glyceryl trinitrate treatment for chronic anal fissure with that among patients receiving percutaneous posterior tibial nerve stimulation. This was a prospective randomized study. The study was conducted at Garcilaso Clinic (Madrid, Spain). Subjects with persistent anal fissure despite hygiene and dietary measures applied over at least a 6-week period were included. Study interventions were perianal application of glyceryl trinitrate ointment (twice daily for 8 weeks) and percutaneous posterior tibial nerve stimulation (30-minute session 2 days per week for 8 weeks). Compliance with the treatment and healing rate of chronic anal fissure in patients receiving glyceryl trinitrate ointment or undergoing percutaneous posterior tibial nerve stimulation were evaluated. Forty patients were included in each group. In the glyceryl trinitrate ointment group, 15% of the patients discontinued treatment because of disabling headaches. There were no adverse effects or treatment withdrawals in the percutaneous posterior tibial nerve stimulation group (p = 0.033). After 8 weeks of treatment, the healing rate in the percutaneous posterior tibial nerve stimulation group was 87.5% vs 65.0% in the glyceryl trinitrate ointment group (p = 0.018). Because the patients were not blinded to the treatment, we cannot rule out a placebo effect derived from the needle insertion in the percutaneous posterior tibial nerve stimulation group. Percutaneous posterior tibial nerve stimulation is a safe and effective alternative that is in some ways superior to glyceryl trinitrate ointment for the treatment of chronic anal fissure.

The internal anal sphincter (IAS) is an important struc ture which is resp onsible to maintain the resting tone . It is known to be responsible for occurrence of fissure in ano. Action of Mahanarayana oil on hypertonic sphincter was evaluated in this study. Three groups were formed with randomly selected forty five patients having symptoms of acute fissure in ano . There were fifteen patients in each group having the age between eighteen to seventy five years. Group I, the control group, was treated with Thriphala Guggulu , Hingvashtaka choorna , Powder Isab gol and sitz bath. Group II was treated with Ointment Diltiazem locally , with sam e regimen as in Gr oup - I. Group III was treated with local application of Mahanarayana oil, with same regimen in G roup - I. All the three groups were underwent ano rectal manometry procedure, before and after treatment by sixteen channel ano rectal manomet ry technique to evaluate resting pressure, squeeze pressure, volume of first sensation and Recto anal inhibitory reflex (RAIR) . It wa s observed that resting pressure (mmHg) within group, compared by pair t test was significantly decreased in Group III after treatment as compared to Group II and I (100.87 ± 30.981SD vs 75.13 ± 12.489SD (P 0.05). Similarly , squeeze pressure, and Volume of first sensation e tc. showed significant difference in Group I II . Hence it can be concluded that Maha narayan a oil local application caused a significant decline in the R esting anal pressure with other parameters and also fo und to be better to relieve the acute spasm of anal sphincter in acute fissure in ano.

Lateral internal sphincterotomy, the most common treatment for chronic anal fissure, may cause permanent injury to the anal sphincter, which can lead to fecal incontinence. We compared two nonsurgical treatments that avert the risk of fecal incontinence. We randomly assigned 50 adults with symptomatic chronic posterior anal fissures to receive treatment with either a total of 20 U of botulinum toxin injected into the internal anal sphincter on each side of the anterior midline or 0.2 percent nitroglycerin ointment applied twice daily for six weeks. After two months, the fissures were healed in 24 of the 25 patients (96 percent) in the botulinum-toxin group and in 15 of the 25 (60 percent) in the nitroglycerin group (P=0.005). No patient in either group had fecal incontinence. At some time during treatment, five patients in the nitroglycerin group had transient, moderate-to-severe headaches that were related to treatment. None of the patients in the botulinum-toxin group reported adverse effects. Ten patients who did not have a response to the assigned treatment - 1 in the botulinum-toxin group and 9 in the nitroglycerin group - crossed over to the other treatment; the fissures subsequently healed in all 10 patients. There were no relapses during an average of about 15 months of follow-up. Although treatment with either topical nitroglycerin or botulinum toxin is effective as an alternative to surgery for patients with chronic anal fissure, botulinum toxin is the more effective nonsurgical treatment.

An anal fissure is a painful linear ulcer in the lower part of the anal canal. It is very often referred to as an ischemic ulcer. Anodermal blood flow is negatively correlated with resting pressure of the anus. Increased activity of the internal anal sphincter may decrease the anodermal blood supply by compressing arterioles. Surgical procedures and botulinum treatment for patients with chronic anal fissure produce a temporary reduction in anal pressure, reverse sphincter spasm, and promote fissure healing. However, recent studies have shown that fissure healing does not appear to be dependent on reduction in mean resting anal pressure. On the basis of the published literature, this article attempts to explain this phenomenon in detail. The mechanism of action of botulinum toxin on the internal anal sphincter is not yet fully understood. This review focuses on problems associated with anal fissure treatment and presents them from the wider angle of science about botulinum toxin. In our opinion, anodermal blood flow depends not only on the "mechanical" force of sphincters but also on biochemical processes that occur in the fissure region.

Objectives: To compare the effectiveness of 0.2% glyceryl trinitrate ointment versus lateral sphincterotomy in management of patients with chronic anal fissure. Materials and Methods: This Comparative study was done in Irfan general hospital THQ Charsadda, and the duration of this study were from April 2022 to September 2022. In this study 80 patients with anal fissure were enrolled. All the patients were divided into two group by lottery method. Group A patients were treated by lateral sphincterotomy while group B was treated by ointment of 0.2% glyceryl trinitrate. A predesign questionnaire were used to collect data. Results: Total 80 patients were enrolled equally divided in to two groups. Group A had 29 (72.5%) male and 11 (27.5%) female while group B had 23 (57.5%) male and 17 (42.5%) female with mean age of 40.47±10.94 years. Group A had 18 (45%) mild pain and 22 (55%) had severe pain while group B had 19 (47.5%) mild pain and 21 (52.5%) severe pain. 23 (57.5%) and 25 (62.5%) patients had bleeding before treatment. The final comparison after 6 weeks of treatment shows the 65% of patients healed with the lateral sphincterotomy and 52.5% of patients healed with ointment of glyceryl trinitrate. The healed proportion was measured high for the lateral sphincterotomy treatment as compared to the ointment of GTN. Practical implication: In our study we find that lateral sphincterotomy is more effective so this study will help the clinical practioner to select the better treatment option inorder to cure the anal fissure soon. Conclusion: It is concluded that for the treatment of anal fissure, the lateral sphincterotomy is considered an effective treatment as compared to ointment of GTN. Keywords: Chronic anal fissure; Glyceryl trinitrate ointment; Lateral internal sphincterotomy

Anal fissure is a common and painful disorder. Its relation to hypertonic anal sphincter is controversial. The most common surgical treatment of chronic anal fissure is lateral internal sphincterotomy. The aim of this study was to evaluate long-term manometric results of sphincter healing following lateral internal sphincterotomy. Between 2000 and 2003, 50 patients with anal fissure were included in this study and underwent sphincterotomy; 12 healthy patients served as controls. All patients with anal fissure underwent manometric evaluation using a 6-channel perfusion catheter. All patients were examined 1 month before surgery and 1, 3, 6, and 12 months following surgery. The control group had 3 manometric evaluations 6 months apart. The mean basal resting pressure before surgery was 138 +/- 28 mm Hg. One month after surgery, the pressure dropped to 86 +/- 15 mm Hg (P < 0.0001) and gradually rose to a plateau at 12 months (110 +/- 18 mm Hg, P < 0.0001). At 12 months, the manometric pressure was significantly lower than the baseline (P < 0.0001). However, manometric measurements in the fissure group were still significantly higher than in the control group (110 +/- 18 versus 73 +/- 4.8 mm Hg, P < 0.0001). All patients were free of symptoms at the 12-month follow-up. Lateral internal sphincterotomy caused a significant decline in the resting anal pressure. During the first year following surgery, the tone of the internal anal sphincter gradually increased, indicating recovery, but still remained significantly lower than before surgery. However, postoperative resting pressures were higher than those in the control, and no patient suffered any permanent problems with incontinence, so this decrease may not be clinically significant.

Anal fissure is common, painful and often associated with increased tone of the anal sphincter.1 About 50% of acute anal fissures heal spontaneously or with conservative treatment (such as local...

Background and objectives. Fissure in ano is one of the most common colorectal diseases seen by surgeons in daily practice. Currently medical management is the first line therapy for treating acute fissure in ano. Apart from general measures, various drugs like nitrates and calcium channel blockers are also used for topical application. Recently topical application of sucralfate and metronidazole are being advocated for in the same way, although there isn't much evidence for their effectiveness. In this study we have compared the efficacy of sucralfate (7% and Metronidazole (1%) ointment to the most commonly used diltiazem (2%) ointment for healing in acute fissure in ano and control of pain. Materials and methods. The present study was a randomized clinical trial with total 96 patients, 47 in the Sucralfate + Metronidazole group and 49 in the Diltiazem group. Both drugs were prescribed for 4 weeks in addition to general measures like sitz bath, laxatives and oral fluids. Patients were followed up at 2 and 4 weeks. Control of symptoms like pain, bleeding and healing of ulcers in both groups were assessed. Frequency or graphs were used for qualitative variables and Mean+/-SD for quantitative variables. Chi-square and t-test was applied for comparison of the two groups, and p-value &lt;0.05 was taken for statistical significance. Results. Most patients were male and belonged to age group 30-50 years. Most patients in both groups improved on conservative treatment. The difference observed in key outcome parameters like control of pain, bleeding and healing of fissure in both groups weren’t found to be statistically significant. Sucralfate and Metronidazole didn’t have any incidence of adverse effects and was cheaper in price compared to diltiazem ointment. Conclusions. Sucralfate and Metronidazole was as effective as diltiazem in treating of acute fissure in ano and can be recommended if allergy and adverse reactions to diltiazem are encountered.

A randomized, double-blind, placebo-controlled trial was performed to test the effect of intra-anal glyceryl trinitrate ointment in patients with chronic anal fissures that would normally have been treated by sphincterotomy. Long-term follow-up was then performed to assess fissure healing. Patients with chronic anal fissures were randomly assigned to 0.2 percent topical glyceryl trinitrate ointment or placebo. Anal manometry was performed before treatment, one week later, and 48 hours after treatment ceased at four weeks. Fissure healing was assessed by an observer blinded to the treatment arm. Pain was recorded on a linear analog scale. At the completion of the trial, treatment was continued with glyceryl trinitrate until fissure healing was obtained or lateral sphincterotomy was performed if required for ongoing pain. A long-term follow-up assessment was made at a mean of 29 (range, 25-33) months. There was a significant reduction in anal resting pressure at Week 1 with glyceryl trinitrate (P = 0.001) but not placebo, and at Week 4 there was a significant reduction in pain score with glyceryl trinitrate (P = 0.001) and placebo (P = 0.01) and a significant reduction in fissure grade with glyceryl trinitrate (P = 0.0001) and placebo (P = 0.02). Forty-six percent of fissures healed with glyceryl trinitrate and 16 percent healed with placebo (P = 0.001). At long-term follow-up in 40 of 43 patients, 14 patients (35 percent) had undergone lateral sphincterotomy, and in the remainder who were treated with glyceryl trinitrate there was a significant reduction in pain score (P = 0.0002). Seventeen patients attended for repeat manometry and fissures were healed with glyceryl trinitrate in ten (59 percent) cases. High internal sphincter pressures persisted at long-term follow-up in patients successfully treated with glyceryl trinitrate, indicating that the sphincter is the cause rather than effect of anal fissure. Topical glyceryl trinitrate produces a successful internal sphincterotomy, which resulted in long-term healing of 59 percent of chronic anal fissures and significant improvement in pain. Internal sphincter spasm is the cause of chronic anal fissure.

The surgical treatment of chronic anal fissure is basically done by therapeutic controlled damage to the internal anal sphincter. While fecal incontinence is a well-documented early complication of anal fissure surgery, few data are available about delayed incontinence. The aim of the present study was to assess whether surgical treatment of anal fissures may contribute to the development of delayed anal incontinence. A retrospective review of patients referred to the Pelvic Floor Laboratory for physiological evaluation of anal incontinence between 1992 and 2009. All patients, diagnosed with anal fissures, who underwent anal dilatation or partial lateral internal sphincterotomy and developed incontinence at least 4years after the surgery were included. Controls were patients with delayed anal incontinence after obstetric injury. A total of 21 patients with delayed post-anal fissure surgery incontinence (nine women and 12 men) were identified. The mean (SE) age of incontinence onset in this group of patients was 51.5 (±2), which was 8years younger than the rest of the 363 incontinent patients (p < 0.001). Time from presumed anal sphincter damage to the onset of incontinence was significantly shorter in the group of past anal-fissure-surgery patients compared to post-obstetric trauma patients (mean difference 15years, p < 0.001). The severity of incontinence was higher in post-obstetric trauma patients. Fecal incontinence may present as a late complication of anal fissure surgery. Incontinence may be associated with other cofactors accumulating over time or, more likely, anal fissure surgery may accelerate the physiologic age-related weakening of the anal sphincter mechanism. Candidates for anal fissure surgery should be informed regarding this possible outcome.

Aim To compare and find out the effectiveness of lateral internal sphincterotomy as well as glyceryl trinitrate in the treatment of anal fissure. Materials &amp; Method A prospective study of 100 patients at the surgery department of a medical college and tertiary health care centre, over a period of 6 months that included cases of fissure in ano in the age group of 18 yrs and 70 years. They were randomly assigned to two different groups. One for surgery and the other for medical management with GTN. Each group had 50 patients in it. Results The pain relief of the patients after the surgical operation was fast and very satisfactory. On follow up at 2 weeks post operatively, pain and other symptoms were present in only 10patients (20%). Whereas the pain relief in medical management group was not fully satisfactory and it took more time.. and it was only temporary and how ever on follow up at 2 weeks, 15 patients came with recurrent pain and other symptoms.(30%). On follow up at 8 weeks, in both groups,all the 100 patients were symptoms free (100%) in this study. The complications that were observed during this study were soiling in 5 patients (10%) and incontinence to flatus in 2 patients (4%) in the surgical group and headache in 10 patients (20%) and peri anal itching in 4 patients (8%) in the medical management group.. how ever there was no recurrence of anal fissure observed in this study group. Conclusion From the above study, it is proved that lateral internal sphincterotomy is by far the best operation for pain relief and rapid cure for fissure in ano

ABSTRACT&#x0D; &#x0D; Anal fissures or tears in the anus are very common. At least 1 in 350 people have experienced an anal fissure. About 20% of anal fissures are accompanied by hemorrhoids. However, there are still few patients or sufferers of anal fissure who know about this condition. Not many doctors or health workers are aware of how to diagnose to primarytreatment or treatment of anal fissures, so patients with anal fissures are often referred directly for surgery. In fact, anal fissures can be treated without surgery, such as dietary modifications. Surgery also has several indications and needs to be considered regarding post-operative complications that can actually be avoided. This article discusses the clinicalmanifestations, diagnosis and management of anal fissures.&#x0D; Keyword: anal fissure, clinical practice, primary care, management.

Anal fissure which is defined as a longitudinal tear in anoderm below the dentate line is one of the most common benign diseases of anorectal area. Severe pain during the defecation and emotional stress that it causes may reduce people's quality of life. In this randomized clinical trial, we aimed to compare the efficiency of the topical ointment with medical treatment and surgical lateral internal sphincterotomy. This is a randomized clinical trial of 550 patients who were treated for chronic anal fissure. Patients were randomly divided into 4 groups according to the treatment type they received. In a vast majority of the patients, the primary complaint was pain (92.3%) and bleeding during defecation (62%). Both pain relief and healing of the fissure, which are the components of response to treatment, had not been observed in 56 (37.3%) patients of topical nitroglycerin ointment group until the second month. Among the recalcitrant patients in both topical nitroglycerin (56) and topical diltiazem ointment (47) groups, 27 (48.2%), and 36 (76.5%) patients underwent surgery, respectively. The best response to treatment was also obtained in lateral internal sphincterotomy group. LIS is still the gold standard for the treatment of chronic anal fissure when the physicians would like to avoid recurrence and obtain the best pain relief.