[Topical use of glyceryl-trinitrate in the treatment of anal fissure]. / Uso topico di gliceril-trinitrato nel trattamento della ragade anale.

AIM: Anal fissure is associated with hypertonia of the internal anal sphincter and pain. Lateral internal sphincterotomy, the most common treatment, may cause permanent injury to the anal sphincter, which can lead to fecal incontinence. The aim of this study was to evaluate the effectiveness of topical glyceryl trinitrate (GTN) ointment in the treatment of anal fissure. METHODS: Twenty-four patients (12 males and 12 females, mean age 45 years) with anal fissure received 0.4% GTN gel twice a day for a minimum of six weeks. All patients were followed at regular intervals of 2, 6, 12 weeks to assess symptom outcome, rate of healing, adverse effects and recurrence rate. RESULTS: The symptomatology was significantly improved already from the second week of treatment in 18 patients (75%). Thirteen patients (54%) healed after six weeks, and 14 (58%) after 12 weeks, while three patients (13%) partially healed but asymptomatic. Fecal incontinence was absent. In two patients (8%) treatment was interrupted because of severe headaches. At the end of the treatment, only three patients (13%) underwent lateral sphincterotomy. CONCLUSIONS: Topical application of GTN ointment heals anal fissures and represents an alternative to the traditional first-line treatment of surgical sphincterotomy.

[Treatment of functional diseases after rectum anal surgery: effectiveness of rehabilitation of the pelvic pavement]. / Trattamento dei disturbi funzionali dopo la chirurgia retto-anale: efficacia della riabilitazione del pavimento pelvico.

AIM: Anorectal dysfunction is routinely treated at the Center for Pelvic Floor Rehabilitation, San Giovanni University Hospital, Turin, Italy. Of a total of 147 patients treated between April 2007 and May 2008, 44 (30%) received pelvic floor rehabilitation following anorectal surgery. With this study we wanted to evaluate the response of patients with constipation and/or fecal incontinence to postsurgical pelvic floor rehabilitation designed to regain full or partial anorectal function and so improve their quality of life. MATERIAL AND METHODS: The study population was 44 patients, subdivided into 3 groups. One group (n=25) consisted of patients with fecal incontinence, which was further split into two subgroups: subgroup A (n=10) with direct involvement of the anal sphincter at surgery and subgroup B (n=15) without sphincter involvement. The second group (n=12) included patients with constipation. The third group (n=7) included patients with constipation and incontinence; this group was further split into 2 subgroups: those in which constipation (n=5) and those in which incontinence (n=2) was predominant. Pre- and postrehabilitation anorectal function was compared using two types of assessment: 1) clinical evaluation with the Wexner incontinence scale and 2) diagnostic evaluation with anorectal manometry in patients with fecal incontinence (plus transanal sonography to determine anatomic damage in the subgroups in which the sphincter had been involved) and defecography in those with constipation (plus transit radiography to exclude intestinal colic-associated constipation). RESULTS: The number of patients classified as having severe incontinence decreased from 8 to 1 (-87.5%), those with moderate incontinence decreased from 8 to 4 (-50%); 20 out of 25 patients presented with mild dysfunction at the end of the rehabilitation program. No difference in response to treatment was found between the two subgroups of patients with fecal incontinence nor among those with constipation. Of those with predominant constipation, none were classified as having severe dysfunction; the number of those with moderate dysfunction decreased from 13 to 7 (-54%). CONCLUSIONS: The study results show that, when sufficiently motivated, patients with fecal incontinence and constipation following anorectal surgery respond positively to pelvic floor rehabilitation.