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• Anal fissure treatment with Glyceryl trinitrate vs. Botulinum toxin
  Dr prem chattoo
  Published on: 4 January 2006

• Published on: 4 January 2006

  Anal fissure treatment with Glyceryl trinitrate vs. Botulinum toxin

  • Dr prem chattoo, Gastroenterology and Hepatology
  • Other Contributors:
    • Dr Shamsul Alam Bhuiyan, Volunteer, NYU Downtown HOspital

  Dear Editor,

  We read this article with great interest. Treatment of anal fissure is really troublesome. Here the author puts emphasis on the Neuromyogenic properties of anal sphincter and treatment by topical glyceryl trinitrate, a nitric oxide donor, which decreases anal sphincter tone and improves anal mucosal blood flow and promotes the healing of anal fissures. Because of the easy application process glyceryl tri...

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  Dear Editor,

  We read this article with great interest. Treatment of anal fissure is really troublesome. Here the author puts emphasis on the Neuromyogenic properties of anal sphincter and treatment by topical glyceryl trinitrate, a nitric oxide donor, which decreases anal sphincter tone and improves anal mucosal blood flow and promotes the healing of anal fissures. Because of the easy application process glyceryl trinitrate becomes popular.

  In a study[1] published in NEJM showe that treatment with either topical nitroglycerin or botulinum toxin is as effective as an alternative to surgery for patients with chronic anal fissure, botulinum toxin is the more effective nonsurgical treatment. Botulism toxin has proved its superiority than nitrates in many clinical trials.Despite the reported success[2] of botulinum toxin, its use has not been widely adopted, possibly due to the need for injection into the sphincter complex and because it is expensive. The optimal dose and method of administration require validation.

  Patients on nitroglycerin at some time in the course of treatment, reported moderate-to-severe headaches after application of the ointment. These headaches were transient (30 to 40 minutes) and were relieved with oral analgesia. some patients may stop applying the ointment because of severe headache. Some patients in the nitroglycerin group reported moderate anal burning. A second potential difficulty is the development of drug tolerance, a problem well documented with nitrate therapy for cardiovascular disease and now also reported during treatment for anal fissure.[3]

  Yet a number of practical and theoretical questions remain unanswered about therapy with nitrates or botulinum toxin. For nitrates: Which preparation should be used, at what concentration, and how often should it be applied? For botulinum toxin: What dose should be used, and where should it be injected — the internal or external sphincter? For both agents: Which works faster and with fewer adverse effects? How substantial is the problem of incontinence, and is it ever more than temporary? What are the relative costs? Finally, what are the long-term relapse rates? If the beauty of chemical sphincterotomy lies in its transience, how often will elevated sphincter pressures lead to recurrence months or years down the road?

  References

  1.A Comparison of Injections of Botulinum Toxin and Topical Nitroglycerin Ointment for the Treatment of Chronic Anal Fissure.Brisinda G., Maria G., Bentivoglio A. R., Cassetta E., Gui D., Albanese A.N Engl J Med 1999; 341:65-69, Jul 8, 1999.

  2. A Comparison of Botulinum Toxin and Saline for the Treatment of Chronic Anal Fissure.Maria G., Cassetta E., Gui D., Brisinda G., Bentivoglio A. R., Albanese A. N Engl J Med 1998; 338:217-220, Jan 22, 1998.

  3.Watson SJ, Kamm MA, Nicholls RJ, Phillips RK. Topical glyceryl trinitrate in the treatment of chronic anal fissure. Br J Surg 1996;83:771 -775.

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  Conflict of Interest:
  None declared.

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