Treating the Anal Sphincter

Treating the Anal Sphincter


The most interesting development in medicinal treatment of hemorrhoids has to do with the use of agents that relax the anal sphincter. There is evidence that hemorrhoid sufferers have increased tightness of the anal sphincter , and some studies are showing that a variety of anal sphincter-relaxing remedies may promote improvement in prolapsed internal hemorrhoids and thrombosed external hemorrhoids, possibly avoiding surgery, or make it possible to to use techniques short of scalpel hemorrhoidectomy .


  • Topical Nitroglycerin in Treatment of Acute Strangulated Internal Hemorrhoids

    In a Netherlands study four male patients (median age 35 years, range 30-42) with acute strangulated hemorrhoids were treated with 1% isosorbide dinitrate. The ointment was applied to the anoderm. This application was repeated every 3 h during daytime for 2 weeks. Significant pain relief was achieved within 1 day, while transient mild headache was experienced during the first 2 days. Within 1 week the hemorrhoids became reducible. Thereafter the hemorrhoids could be treated adequately by rubber band ligation.
    Int J Colorectal Dis 2000 Aug;15(4):253-4 (ISSN: 0179-1958) Briel JW; Zimmerman DD; Schouten WR]

  • Topical nifedipine for acute thrombosed external hemorrhoids

    An article in a GI journal (Dis Colon Rectum 2001 Mar;44(3):405-9 ) appeared regarding a study done in Italy at the Cardarelli Hospital in Naples. 50 patients with acute , thrombosed external hemorrhoids were treated with a topical nifedipine ointment (.3% with 1.5% lidocaine) every 12 hrs compared with a control group of 48 patients who just receive topical lidocaine (a topical numbing med) without the nifedipine. There was a substantial difference in time to pain relief and in time to resolution of the hemorrhoids between the 2 groups.
    (Nifedipine is a calcium channel blocker usually administered as a pill for hypertension and other cardiac disorders) This sounds like a most useful and safe remedy for those wishing to avoid the scalpel and other non medical treatments, but there is no marketed version of this remedy, at least that I can find. Pharmacies which make custom formulations may be able to make some up if your physician prescribes this .



    ANAL FISSURES have been found to be associated with increased anal sphincter muscle tone, and the research demonstrating fissure healing with calcium channel blockers and other agents may be applicable to external hemorrhoids......
    [See Neuromyogenic properties of the internal anal sphincter: therapeutic rationale for anal fissures. Gut 2000 Jun;46(6):861-8 (ISSN: 0017-5749) Bhardwaj R; Vaizey CJ; Boulos PB; Hoyle CH ]


  • Topical Diltiazem and Bethanechol Show Healing of Anal Fissures

    A United Kingdom study at St. Mark's hosital , London, looked a the use of 2 % diltiazem gel or 0.1 % bethanechol gel three times daily for eight weeks. All patients had chronic anal fissures. RESULTS: Fissures healed in 10 of 15 (67 percent) patients treated with 2 % diltiazem gel and in 9 (60 percent) patients treated with 0.1 % bethanechol gel. Significant pain reduction accompanied the healing.
    [Diltiazem is a calcium channel blocker, betanechol is a "cholinomimetic." (more info to follow)
    Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects. Dis Colon Rectum 2000 Oct;43(10):1359-62 (ISSN: 0012-3706) Carapeti EA; Kamm MA; Phillips RK]

    (SEE BOTTOM OF THIS PAGE FOR RECENT DISCUSSION ON TOPICAL AGENTS)

  • Oral Use of Calcium Channel Blockers in Anal Fissure Healing

    Interestingly, ORAL use of Nifedipine or Diltiazem has also been shown to reduce anal sphincter pressure and promote anal fissure healing.
    Keep in mind that these oral meds -- calcium channel blockers -- can be constipating !
    See :
    (1) [ A randomized trial of oral vs. topical diltiazem for chronic anal fissures. Dis Colon Rectum 2001 Aug;44(8):1074-8 (ISSN: 0012-3706) Jonas M; Neal KR; Abercrombie JF; Scholefield JH ]
    (oral diltiazem was not as effective as topical med and was associated with more side effects)

    (2) [Oral nifedipine reduces resting anal pressure and heals chronic anal fissure. Br J Surg 1999 Oct;86(10):1269-73 (ISSN: 0007-1323) Cook TA; Humphreys MM; McC Mortensen NJ ]
    (this study showed that oral nifedipine, like the topical version, can also promote anal fissure healing, with tolerable side effects in some patients)


  • Also, check out this web site's info on CRYOTHERAPY . The anal sphincter will relax when it is made either warm or cold.



  • E-mail discussion on topical agents, ASCRS


    (Colorectal surgeons from Amercican Society of Colon/Rectal Surgeons have an E-mail exchange on topical calcium channel blockers)

    From: SF
    To: ASCRS
    Sent: Sunday, October 27, 2002 10:25 PM
    Subject: Re: Topical Medications for Anal Fissure

    > I have the pharmacist mix 60 mg of nifedipine (adalat) in 30 gm of petroleum
    > jelly. This is 0.2% concentration. I've stopped using nitroglycerine, I
    > can't remember a patient who it either worked on or was tolerated . The
    > adalat seems very well tolerated and seems to at least work in some
    > patients. Basically I tell them to use the adalat, stool softeners
    and see
    > how they go. If they are still miserable in 4-6 weeks, I will offer
    them an
    > operation. I've had limited experience with Botox, seems to work,
    but
    > nothing works as well as an operation. Personally if I had a
    fissure, I
    > would give the Botox a try, if it doesn't work, can always do the
    > sphincterotomy later.
    >
    > SF
    > Toronto

    -------------------------
    Date: Mon, 28 Oct 2002 17:25:54 -0000
    From: NR
    Subject: Re: Topical Medications for Anal Fissure

    Our Pharmacist also uses petrolatum but we use 2% Nifedipine and not
    0.2%. I
    think the manufacturers of Adalat are already making the ointment. So
    your
    pharmacist can relax.
    NR
    Consultant Colorectal surgeon
    UK.

    ----------------------------
    Date: Tue, 29 Oct 2002 17:48:05 EST
    From: RP
    Subject: Re: Topical Medications for Anal Fissure

    Joshua
    I talked with my pharmacist and we do use 0.2% Nifedipine ointment. He
    also
    makes a suppository that combines Xylocaine 5% and the 0.2% Nifedipine.
    In
    reference to the article by Jonas et al.they use topical 2% Diltiazem
    with
    good results when compared with oral. I feel the same way as Stan, the
    incidence of side effects is much lower with Nifedipine than with NTG.
    It
    would be interesting to try a 2%Nifedipine plus Xylocaine 5%
    suppository and
    see how it works out.

    Sincerely,
    RP MD FASCRS
    West VA

    ---------------------------
    Date: Wed, 30 Oct 2002 16:57:14 -0500
    From: JK
    Subject: Re: Topical Medications for Anal Fissure

    Thanks. I will try this. What is the mixing agent for the nifedipine
    (or do you just mix it with the 5% xylocaine.

    JK, M.D.
    George Washington University School of Medicine

    -----------------------------
    Date: Wed, 30 Oct 2002 18:03:30 EST
    From: RP
    Subject: Re: Topical Medications for Anal Fissure

    Joshua:
    The mixture is called MBK and is a fatty acid base that is used for
    the
    suppositories, the reason you have different concentrations in the
    preparations is that they (in U.K.)are using different type of Ca
    Channel
    blocker (Nifedipine vs Diltiazem) look article DCR 1999,Vol 42 No 8 pg.
    1011,
    this was a multicenter study out of Univ. of Naples, Italy by Antropoli
    et al
    they used Nifedipine 0.2% gel. they obtained an impressive 95%
    remission in
    nifedipine treated pts at 21 days. Obviously some of those patients
    will
    recurr after they stop the medication.
    Sincerely

    RP, MD, FASCRS
    West Va

    -----------------------------
    Date: Thu, 31 Oct 2002 19:15:45 -0500
    From: D and D
    Subject: Re: Topical Medications for Anal Fissure

    Nagesh:

    nifedipine(Procardia, Adalat) and diltiazem(Cardizem, Cartia) are the
    generic names. They are both Ca channel blockers, but are different
    drugs with different pharmacologic properties.

    ------------------------------
    Date: Thu, 31 Oct 2002 21:02:41 EST
    From: RP
    Subject: Re: Topical Medications for Anal Fissure

    Nagesh
    Diltiazem and Nifedipine ARE generic names!
    I have the feeling that Nifedipine is stronger than Diltiazem that is
    the
    reason that you guys use 2% concentration instead of 0.2.
    Sincerely,
    RP MD FASCRS
    West Va

    -------------------------------
    Date: Thu, 31 Oct 2002 23:50:33 -0000
    From: N
    Subject: Re: Topical Medications for Anal Fissure

    Roger,
    I think, Nifedipine and Diltiazem are one and the same. Are you not
    getting
    confused with the generic and pharmacological names!!!!

    N

    ---------------------------------
    Date: Thu, 31 Oct 2002 08:32:34 +0100
    From: EL
    Subject: topical medications in anal fissure

    Does anyone know the profile of safety of topical medications in
    pregnancy or in lactating women?
    My last two "fissure patients" were a pregnant woman in the first
    trimester and a lactating woman.
    I prescribed a course of Dilatan (Sapimed, Italy), in order to achieve
    a
    progressive dilatation by threee progressive plastic anal dilators.

    EL
    Ospedale civile di Pescara
    Italy

    --------------------------
    Date: Fri, 1 Nov 2002 22:21:31 +0200
    From: HP and DP
    Subject: Re: Topical Medications for Anal Fissure

    No they are not. Although they are both calcium channel blockers, they
    are very different, including their affect on the cardiovascular
    system.
    Furthermore, diltiazem is water soluble while nifedipine is almost
    insoluble in water.
    I have been following this discussion for a while and it seems that
    there are a lot of confusion regarding preparations with these two
    drugs.
    For the treatment of anal fissures either one can use either nifedipine
    0.2% or diltiazem 2%. The two preparations are different mainly due to
    the difference in solubility in water. You should consult with your
    pharmacist and he will advise you on which he can best produce.
    Anyhow don't confuse, they are NOT the same.
    As for nitroglycerine preparations it is always 0.2%.

    HP
    Dept. of Surgery "A"
    Meir Hospital, Kfar-Sava
    Israel

    ----------------------------
    Date: Fri, 1 Nov 2002 11:04:01 -0500
    From: JK
    Subject: Re: Topical Medications for Anal Fissure

    Nifedipine and Dilitiazem are both calcium channel blockers; nifedipine
    acts more peripherally and has almost no antiarrythmic effect.
    Diltiazem act more centrally and can be used as an antiarrythmic.
    Prior
    to this exchange I was unaware that topical nifedipine could be use for
    perianal disease; the only literature I have is on Diltiazem.

    JK, M.D.

    George Washington University School of Medicine



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