• Muhammad Siddique Khan Ayub Teaching Hospital,Abbottabad
  • Ismail Abar
  • Juniad Zeb
  • Salman Ahmad
  • Ajmal Khan


Background: Anal fissure is a linear tear in the distal anal canal resulting from persistent hypertonia and spasm of the internal sphincter which results in mucosal ischemia. We have conducted a study in order to compare the outcome of 0.2% glyceryl trinitrate cream versus 2% diltiazem cream in the treatment of chronic anal fissure Methods: This randomized controlled trial (RCT) was carried out in the Department of Surgical “B” unit, at Ayub Teaching Hospital, Abbottabad, Pakistan from 15th June 2012 to 15th May 2015. One hundred and eighty-four patients who visited the outpatient department for the treatment of chronic anal fissure were included in the study. They were divided into two groups with 92 patients in each group. Patients in group “A” included those patients receiving topical glyceryl trinitrate and group “B” patients were those receiving topical diltiazem cream. Results: Out of 184 patients 66.3% were males, 33.7% were females. Mean age of the patients was 43.84±7.976 and mean duration of symptoms was 10.55±2.524. Overall outcome in terms of healing was 71.2%, among which 80.4% were from diltiazem group while 62% in glyceryl trinitrate group. Complete relief of pain was observed in 67.9%, 26.1% complained of mild pain and 5.4% complained of moderate pain. Only one patient in glyceryl trinitrate group complained with severe pain with no healing after one month of follow up. No statistical association was found between healing outcome and gender as well as age of the patients (p>0.05) although an association was found between healing outcome and duration of symptoms (p<0.05). Conclusion: This study shows that diltiazem has better outcome in terms of healing of chronic anal fissure and reductions in symptoms, i.e., pain compared with glyceryl trinitrate. Keywords: Chronic anal fissure; Diltiazem; glyceryl trinitrate; cream; chemical sphincterotomy

Author Biography

Muhammad Siddique Khan, Ayub Teaching Hospital,Abbottabad

junier registrar Surgical B ward ,Ayub Teaching Hospital Abbottabad


Aziz M, Kiani F, Qasmi SA. Comparison between lateral internal anal sphincterotomy and diltiazem in the treatment of chronic anal fissure. J Surg Pak 2012;17(1):16–9.

Suvarna R, Hanumanthappa MB, Panchami Rai DG. Topical diltiazem versus topical glyceryl trinitrate (GTN) in the treatment of chronic anal fissure: prospective study. Int J Biol Med Res 2012;3(2):1747–50.

Hashmi F, Siddiqui FG. Diltiazem (2%) versus glyceryltrinitrate cream (0.2%) in the management of chronic anal fissure. J Coll Physicians Surg Pak 2009;19(12):750–3.

Rahman SS, Mansoor SN. Effectiveness of Glyceryl trinitrate in the treatment of chronic anal fissure. Ann Punjab Med Coll 2011;5(2):106–10.

Sauper T, Lanthaler M, Biebl M, Weiss H, Nehoda H. Impaired anal sphincter function in professional cyclists. Wien Klin Wochenschr 2007;119(5-6):170–3.

Garg P. Water stream in a bidet-toilet as a cause of anterior fissure-in-ano: a preliminary report. Colorectal Dis 2010;12(6):601–2.

Jenkins JT, Urie A, Molloy RG. Anterior anal fissures are as- sociated with occult sphincter injury and abnormal sphincter function. Colorectal Dis 2008;10(3):280–5.

Nzimbala MJ, Bruyninx L. Chronic anal fissure from suspected adult sexual abuse in a traumatic anal sex practice patient. Acta Chir Belg 2007;107(5):566–9.

Nzimbala MJ, Bruyninx L, Pans A, Martin P, Herman F. Chronic anal fissure: common aetiopathogenesis, with special attention to sexual abuse. Acta Chir Belg 2009;109(6):720–6.

Lund JN, Scholefield JH. Aetiology and treatment of anal fissure. Br J Surg 1996;83(10):1335–44.

Brisinda G, Cadeddu F, Brandara F, Brisinda D, Maria G. Treating chronic anal fissure with botulinum neurotoxin. Nat Clin Pract Gastroenterol Hepatol 2004;1(2):82–9.

Perry WB, Dykes SL, Buie WD, Rafferty JF. Practice parameters for the management of anal fissures (3rd revision). Dis Colon Rectum 2010;53(8):1110–5.

Farid M, El Nakeeb A, Youssef M, Omar W, Fouda E, Youssef T, et al. Idiopathic hypertensive anal canal: a place of internal sphincterotomy. J Gastrointest Surg 2009;13(9):1607–13.

Golfam F, Golfam P, Khalaj A, Sayed Mortaz SS. The effect of topical nifedipine in treatment of chronic anal fissure. Acta Med Iran 2010;48(5):295–9.

Medhi B, Prakash A, Upadhyay S, Xess D, Yadav TD, Kaman L. Comparison of observational and controlled clinical trials of diltiazem in the treatment of chronic anal fissure. Indian J Surg 2011;73(6):427–31.

Sanei B, Mahmoodieh M, Masoudpour H. Comparison of topical glyceryl trinitrate with diltiazem ointment for the treatment of chronic anal fissure: a randomized clinical trial. Acta Chir Belg 2009;109(6):727–30.

Jawaid M, Masood Z, Salim M. Topical diltiazem hydrochloride and glyceryl trinitrate in the treatment of chronic anal fissure. J Coll Physicians Surg Pak 2009;19(10):614–7.

Collins EE, Lund JN. A review of chronic anal fissure management. Tech Coloproctol 2007;11(3):209–23.

Soybel DI. What causes anal fissure? Gastroenterology 1996;111(4):1154–5.

Tomar V, Saxena A. Establishing the Superiority of Topical Diltiazem over Glyceryl Trinitrate in the Treatment of Chronic Anal Fissure: a Prospective Analytical Study. Glob J Surg 2014;2(3):37–41.

Pardhan A, Azami R, Mazahir S, Murtaza G. Diltiazem vs. glyceryl tri-nitrate for symptomatic relief in anal fissure: a randomised clnical study. J Pak Med Assoc 2014;64(5):510–3.

American Gastroenterological Association. American Gastroenterological Association medical position statement: Diagnosis and care of patients with anal fissure. Gastroenterology 2003;124(1):233–4.

Brisinda G, Albanese A, Cadeddu F, Bentivoglio AR, Mabisombi A, Marniga G, et al. Botulinum neurotoxin to treat chronic anal fissure: results of a randomized "Botox vs. Dysport" controlled trial. Aliment Pharmacol Ther 2004;19(6):695–701.

Griffin N, Acheson AG, Tung P, Sheard C, Glazebrook C, Scholefield JH. Quality of life in patients with chronic anal fissure. Colorectal Dis 2004;6(1):39–44.

Kennedy ML, Sowter S, Nguyen H, Lubowski DZ. Glyceryl trinitrate ointment for the treatment of chronic anal fissure: results of a placebo-controlled trial and long-term follow-up. Dis Colon Rectum 1999;42(8):1000–6.

Gagliardi G, Pascariello A, Altomare DF, Arcanà F, Cafaro D, La Torre F, et al. Optimal treatment duration of glyceryl trinitrate for chronic anal fissure: results of a prospective randomized multicenter trial. Tech Coloproctol 2010;14(3):241–8.

Sands LR. 0.4% nitroglycerin ointment in the treatment of chronic anal fissure pain: A viewpoint by Laurence R. Sands. Drugs 2006;66(3):350–2.