Sphincterotomy vs. Nitroglycerin for Chronic Anal Fissure: Long-Term Follow-Up

Cure rate was higher and patients were more satisfied with sphincterotomy.
Chronic anal fissure usually is treated with nitroglycerin ointment, botulinum toxin (Botox) injection, or lateral internal sphincterotomy. All three treatments decrease anal sphincter pressure and improve anal blood flow. Lateral internal sphincterotomy has the highest cure rate but has been associated with postoperative incontinence in retrospective studies.
Now, researchers report 6-year follow-up results from a randomized controlled trial in which 82 patients received thrice-daily nitroglycerin ointment (0.25%) or underwent lateral internal sphincterotomy. Participants were enrolled from February 1997 through October 1998. Sixty-two percent of patients (27 in the nitroglycerin arm and 24 in the sphincterotomy arm) responded to a telephone survey in 2004 about treatment outcomes.
Recurrent fissure symptoms were less likely to have occurred in the sphincterotomy arm than in the nitroglycerin arm (0% vs. 41%; P=0.0004), and sphincterotomy patients were less likely to have required additional surgical treatment (0% vs. 59%; P<0.0001). The sphincterotomy patients were more likely to say that they were "moderately" or "very" satisfied with treatment (100% vs. 56%; P=0.04) and that they would use the same therapy again (92% vs. 63%; P=0.02). Fecal incontinence scores were similar in the two groups.
Comment: Provided that a surgeon who is skilled in lateral internal sphincterotomy is available, few downsides to this procedure exist. Initial use of topical nitroglycerin or Botox injection still is reasonable, but, given these data, repeated courses of medical therapy probably are not the best choice for patients with recurrent or persistent chronic fissure.
— Douglas K. Rex, MD
Published in Journal Watch Gastroenterology June 29, 2007
Citation(s):
Brown CJ et al. Lateral internal sphincterotomy is superior to topical nitroglycerin for healing chronic anal fissure and does not compromise long-term fecal continence: Six-year follow-up of a multicenter, randomized, controlled trial. Dis Colon Rectum 2007 Apr; 50:442-8.