INTRODUCTION
The duration of physiologic action of topical glyceryl trinitrate in the management of anal fissure has been the source of some controversy. This study was designed to assess the manometric effect of glyceryl trinitrate on internal sphincter resting tone with continuous monitoring.
METHODS
Twenty-seven patients with a chronic anal fissure were assessed with fissure, pain, bleeding, and continence scores. Twenty-two were randomized to 1 cm of topical 0.2 percent glyceryl trinitrate paste, applied to the lower anal canal. Five patients were randomized to 1 cm of water-soluble lubricating jelly to the lower anal canal. Continuous stationary six radial channel water perfusion anorectal manometry was performed for 5 minutes before treatment and then for a further 30 minutes. The 22 glyceryl trinitrate patients were then advised to apply topical 0.2 percent glyceryl trinitrate, three times daily, for eight weeks. Twenty-four hours after completing treatment, all baseline assessments were repeated. The lubricant jelly cohort was discharged from the study after the initial assessment.
RESULTS
During the initial manometric assessment, 21 glyceryl trinitrate patients (95 percent) had 20 percent or more reduction in mean and maximum anal resting pressure after treatment. However, there was no statistical difference at 20 minutes compared with 0 minutes (P > 0.1). After eight-week treatment, 16 patients (73 percent) reported symptom resolution and 15 (67 percent) were found to be healed on examination. Clinical healing and resolution of symptoms positively correlated with a higher pretreatment maximum anal resting pressure in the mid anal canal (P < 0.0001), lower fissure score (P < 0.0001), and greater percentage reduction of the maximum resting pressure after application of glyceryl trinitrate (P < 0.001). The mean and maximum anal resting pressure at Week 8 was not significantly different from the baseline values (P > 0.05). During continuous manometry, the anal resting pressure did not significantly change in the patients treated with lubricating jelly.
CONCLUSIONS
In those patients with a lower fissure score, a higher mid anal canal anal resting pressure, and a greater resting pressure reduction after glyceryl trinitrate application, a favorable clinical outcome can be expected with glyceryl trinitrate treatment. However, because the physiologic response has resolved in fewer than 20 minutes, the dosing regime should be reassessed.
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REFERENCES
BD Hancock (1977) ArticleTitleThe internal anal sphincter Br J Surg 64 92–5 Occurrence Handle1:STN:280:DyaE2s3ktlaitw%3D%3D Occurrence Handle890253
CP Gibbons NW Read (1986) ArticleTitleAnal hypertonia in fissures: cause or effect? Br J Surg 73 443–5 Occurrence Handle1:STN:280:DyaL283ktl2quw%3D%3D Occurrence Handle3719268
WR Schouten JW Briel JJ Auewerda (1994) ArticleTitleRelationship between anal pressure and anodermal blood flow: the vascular pathogenesis of anal fissure Dis Colon Rectum 37 664–9 Occurrence Handle1:STN:280:DyaK2c3pvVCitw%3D%3D Occurrence Handle8026232
B Klosterhalfen P Vogel H Rixen C Mittermayer (1989) ArticleTitleTopography of the inferior rectal artery: a possible cause of chronic, primary anal fissure Dis Colon Rectum 32 43–52 Occurrence Handle1:STN:280:DyaL1M%2FptVOmtA%3D%3D Occurrence Handle2910660
JN Lund C Binch J McGrath RA Sparrow JH Scholefield (1999) ArticleTitleTopographical distribution of blood supply to the anal canal Br J Surg 86 496–8 Occurrence Handle10.1046/j.1365-2168.1999.01026.x Occurrence Handle1:STN:280:DyaK1M3jtlOltQ%3D%3D Occurrence Handle10215822
I Lindsey OM Jones C Cunningham NJ Mortensen (2004) ArticleTitleChronic anal fissure Br J Surg 91 270–9 Occurrence Handle10.1002/bjs.4531 Occurrence Handle1:STN:280:DC%2BD2c7gtVSntA%3D%3D Occurrence Handle14991625
R Madoff JW Fleshman (2003) ArticleTitleAmerican Gastroenterology Association medical position statement: diagnosis and care of patients with anal fissure Gastroenterology 123 233–4
PB Loder MA Kamm RL Nicholls RK Phillips (1994) ArticleTitle“Reversible chemical sphincterotomy” by local application of glyceryl trinitrate Br J Surg 81 372–6
DF Altomare M Rindali G Milito et al. (2000) ArticleTitleGlyceryl trinitrate for chronic anal fissure: healing or headache? Results of a multicenter, randomized, placebo-controlled, double-blind trial Dis Colon Rectum 43 174–81 Occurrence Handle1:STN:280:DC%2BD3c7lvF2lsQ%3D%3D Occurrence Handle10696890
J Pitt K Dawas PM Dawson (1999) ArticleTitleDisappointing results of glyceryl trinitrate ointment in treatment of chronic fissure-in-ano in a district general hospital Colorectal Dis 1 204–6 Occurrence Handle10.1046/j.1463-1318.1999.00042.x
GJ Oettle (1997) ArticleTitleGlyceryl trinitrate vs. sphincterotomy for treatment of chronic anal fissure: a randomized, controlled trial Dis Colon Rectum 40 1318–20 Occurrence Handle1:STN:280:DyaK1c%2FjsVSguw%3D%3D Occurrence Handle9369106
H Bacher HJ Mischingeer G Werkgartner et al. (1997) ArticleTitleLocal nitroglycerine for treatment of anal fissures: an alternative to lateral sphincterotomy? Dis Colon Rectum 40 840–5 Occurrence Handle1:STN:280:DyaK2szmsV2itw%3D%3D Occurrence Handle9221864
JN Lund JH Scholefield (1997) ArticleTitleGlyceryl trinitrate is an effective treatment for anal fissure Dis Colon Rectum 40 468–70 Occurrence Handle1:STN:280:DyaK2s3mtVGkug%3D%3D Occurrence Handle9106698
AJ Malouf CS Norton AF Engel RJ Nicholls MA Kamm (2000) ArticleTitleLong-term results of overlapping anterior anal-sphincter repair for obstetric trauma Lancet 355 260–5 Occurrence Handle1:STN:280:DC%2BD3c7jslGgtQ%3D%3D Occurrence Handle10675072
ML Kennedy S Sowter H Nguyen DZ Lubowski (1999) ArticleTitleGlyceryl trinitrate ointment for the treatment of chronic anal fissure Dis Colon Rectum 42 1000–6 Occurrence Handle1:STN:280:DyaK1MzosFejsQ%3D%3D Occurrence Handle10458121
HR Bailey DE Beck RP Billingham et al. (2002) ArticleTitleA study to determine the nitroglycerine ointment dose and dosing interval that best promote the healing of chronic anal fissures Dis Colon Rectum 45 1192–9 Occurrence Handle10.1007/s10350-004-6392-9 Occurrence Handle12352236
HB Hechtman C Barlow (1996) ArticleTitleModeration of anal sphincter tone with nitric oxide agonists and antagonists Arch Surg 131 775–8 Occurrence Handle1:STN:280:DyaK283ptVCqtw%3D%3D Occurrence Handle8678781
M Jonas A Amin JW Wright KR Neal JH Scholefield (2001) ArticleTitleTopical 0.2 percent glyceryl trinitrate ointment has a short-lived effect on resting anal pressure Dis Colon Rectum 44 1640–3 Occurrence Handle1:STN:280:DC%2BD3MnmsFKhuw%3D%3D Occurrence Handle11711736
F Guillemot H Leroi YC Lone CG Rousseau MD Lamblin A Cortot (1993) ArticleTitleAction of an in situ nitroglycerine on upper anal canal pressure of patients with terminal constipation: a pilot study Dis Colon Rectum 36 372–6 Occurrence Handle1:STN:280:DyaK3s3gvFSqsA%3D%3D Occurrence Handle8458265
JD Cundall JR Easterbrook JV Tilsed GS Duthie (2001) ArticleTitleThe dose response of the internal anal sphincter to topical application of glyceryl trinitrate ointment Colorectal Dis 3 259–62 Occurrence Handle10.1046/j.1463-1318.2001.00248.x Occurrence Handle1:STN:280:DC%2BD3s3msFSgtQ%3D%3D Occurrence Handle12790969
G Brisinda G Maria G Sganga et al. (1999) ArticleTitleA comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure N Engl J Med 341 65–9 Occurrence Handle10.1056/NEJM199907083410201 Occurrence Handle1:CAS:528:DyaK1MXks1GlsLc%3D Occurrence Handle10395629
SS Rao R Hatfield E Soffer S Rao J Beaty JL Conklin (1999) ArticleTitleManometric tests of anorectal function in healthy adults Am J Gastroenterol 94 773–83 Occurrence Handle10.1111/j.1572-0241.1999.00950.x Occurrence Handle1:STN:280:DyaK1M7osVCluw%3D%3D Occurrence Handle10086665
WM Sun TC Donnelly NW Read (1989) ArticleTitleAnorectal function in normal human subjects: effect of gender Int J Colorectal Dis 4 188–96 Occurrence Handle10.1007/BF01649702 Occurrence Handle1:STN:280:DyaL1MzmtV2hsg%3D%3D Occurrence Handle2769003
JO Keck RJ Staniunas JA Coller RC Barrett ME Oster (1995) ArticleTitleComputer-generated profiles of the anal canal in patients with anal fissure Dis Colon Rectum 38 72–9 Occurrence Handle1:STN:280:DyaK2M7ht1Ojsg%3D%3D Occurrence Handle7813351
EA Carapeti MA Kamm PJ McDonald SJ Chadwick D Melville RK Phillips (1999) ArticleTitleRandomised controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate Gut 44 727–30 Occurrence Handle1:CAS:528:DyaK1MXjtF2kt74%3D Occurrence Handle10205213 Occurrence Handle10.1136/gut.44.5.727
BF Zuberi MR Rajput H Abro SA Shaikh (2000) ArticleTitleA randomised trial of glyceryl trinitrate ointment and nitroglycerine patch in healing anal fissures Int J Colorectal Dis 15 243–5 Occurrence Handle1:STN:280:DC%2BD3cvlt1entg%3D%3D Occurrence Handle11008725
Thornton MJ, Kennedy ML, King DW, Lubowski DZ. Long-term follow-up of the dynamic graciloplasty reconstruction for faecal incontinence. Colorectal Dis 2004;6:470–6
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Supported by the Harry Triguboff Colorectal Research Scholarship, administered through Sydney Colorectal Associates.
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Thornton, M., Kennedy, M. & King, D. Manometric Effect of Topical Glyceryl Trinitrate and Its Impact on Chronic Anal Fissure Healing. Dis Colon Rectum 48, 1207–1212 (2005). https://doi.org/10.1007/s10350-004-0916-1
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DOI: https://doi.org/10.1007/s10350-004-0916-1