What is second-line medical therapy for anal fissure?

Updated: Nov 28, 2018
  • Author: Lisa Susan Poritz, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Second-line medical therapy consists of intra-anal application of 0.4% nitroglycerin (NTG; also called glycerol trinitrate) ointment directly to the internal sphincter. [5] Nitroglycerin rectal ointment is approved by the US Food and Drug Administration (FDA) for moderate-to-severe pain associated with anal fissures and may be considered when conservative therapies have failed. [6]

Some physicians use NTG ointment as initial therapy in conjunction with fiber and stool softeners, and others prefer to add it to the medical regimen if fiber and stool softeners alone fail to heal the fissure. NTG ointment is thought to relax the internal sphincter and to help relieve some of the pain associated with sphincter spasm; it also is thought to increase blood flow to the anal mucosa.

Unfortunately, many people cannot tolerate the adverse effects of NTG, and as a result, its use is often limited. The main adverse effects are headache and dizziness; therefore, patients should be instructed to use NTG ointment for the first time in the presence of others or directly before bedtime.

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