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234 Hemorrhoids and perianal pain
an opportunity to institute what has been termed “reversible chemical
sphincterotomy.” 11 Trial evidence shows that, while not as effective as exci-
sion in long-term follow-up, topical nitroglycerin ointment (0.2%) provides
significantly better pain relief than does incision. 12 When topical nitrogly-
cerin is used for chronic anal fissure, significant pain relief occurs in about
two thirds of patients; symptom relief may be achieved even if anal fissures
and ulcers are not healed. 8,9,11 The existence of conflicting data must be
acknowledged. An RCT in patients receiving stool softeners and sitz baths
(see below) found no additional symptom relief from addition of topical
nitroglycerin in either a 0.2% or 0.4% concentration. 13 The bulk of the
evidence, however, suggests that administration of nitroglycerin can provide
rapid (within 2–6 h) and significant relief of pain from anal fissures, ulcers, or
external hemorrhoids. 9 Furthermore, RCT data show that topical nitroglycerin
provides better relief than many alternative therapies. For instance,
when used for treatment of chronic anal fissures, topical nitroglycerin provides
significantly better pain relief than application of placebo (petrolatum),
topical anesthetic (lidocaine 5%), or a compound of hydrocortisone, heparin,
framycetin sulfate, esculoside, ethoform, and butoform. 14
Although the occasionally conflicting data about nitroglycerin’s efficacy is
responsible for some clinicians’ decision to avoid the drug, side effects are a
more important consideration. Even when administered topically, nitroglycerin
use risks headache development. The cephalalgia rate varies, and
it must be acknowledged that one RCT found no difference between headache
rates for patients using nitroglycerin and those using placebo (20% in
both groups). 15 However, most of the available data suggest a 10–20% incremental
incidence of headache in nitroglycerin users. Unlike nitroglycerin use
in acute coronary syndromes, where the risk-to-benefit ratio favors nitroglycerin
use even at a cost of headache, patients with perianal conditions
may not wish to take extra (anti-headache) analgesics and thus will not use
the nitroglycerin. 10,13,16–18
There are routes to control headache risk in patients in whom clinicians
wish to use nitroglycerin. First, the literature suggests that the lower concentrations
(i.e. 0.2%) of nitroglycerin are effective. Thus, clinicians choosing to
use nitroglycerin should institute therapy with 0.2% ointment, twice daily.