Avoiding surgery with a simple self-treatment.

Until now, surgery has been the only definitive treatment for chronic anal fissure, a painful condition with a variety of causes. Anal fissure affects all age groups, from infancy to old age, but the peak incidence is in the 10-30 age group. In infants, it is the most common cause of rectal bleeding. Fortunately, most fissures in infants do not become chronic, and many will heal spontaneously.

An anal fissure is a crack in the lining of the anal canal. Fissures may occur without an underlying condition, or they may be secondary to Crohn's disease, leukemia, damage from a foreign body, childbirth, or previous anal surgery. An acute fissure is superficial--no more than a crack in the tissue around the anus, without any surrounding scarring. It resolves spontaneously or with conservative treatment, such as the use of bulk laxatives or warm sitz-baths.

The conventional wisdom has often attributed fissures to constipation, but some studies have shown less than 20 percent of persons with fissures giving a history of constipation--and prolonged diarrhea secondary to laxative abuse is often a cause. Whatever the cause, fissures that do not respond to conservative treatment usually require surgery for relief of the painful defecation and rectal bleeding that characterize the condition. The procedure is called sphincterotomy--partially cutting the ring of muscle (the anal sphincter) that surrounds the anus and controls defecation. The effect is to reduce anal pressure, allowing the fissure to heal. In a small percentage of cases, however, long-term anal incontinence is a complication of surgery.

A study reported in the British medical journal Lancet (January 4, 1997) may be responsible for relegating surgical treatment of anal fissure to the archives of medical history insofar as many sufferers are concerned. Half a group of 80 randomly selected patients with chronic anal fissure was given glyceryl trinitrate (GTN) ointment to apply to the lower anal canal twice a day. After eight weeks, the fissures had healed in 68 percent of them, compared to only 8 percent of those given a placebo ointment.

Measuring resting pressure in the anal sphincter, the researchers found that GTN effectively reduced the pressure, producing a "chemical sphincterotomy." Those in the placebo group showed no change in anal resting pressure. Although both groups had some reduction in their pain at the beginning of the trial period, only the GTN users were free of pain after four weeks. About half the GTN users experienced headaches at some point in the trial period, but only one dropped out of the study because of this side effect.