This article found that 0.2% nitroglycerin ointment was effective in resolving anal fissures and associated symptoms in younger pediatric patients. Nitroglycerin helps with anal fissures as it relaxes the internal anal sphincter, maintains the sphincter at a lower resting pressure than usual, and increases perfusion to the anal mucosa, as well as treats pain resulting from spasm of the sphincter.  The sample size included 105 patients between the ages of 4 months and 5 years, with 70 in the control group, and 35 in the treatment group. Both groups had a regimen of Sitz baths, stool softeners, and local anesthetic, with the control group also being advised to apply the 2% nitroglycerin ointment endoanally twice daily for 8 weeks (12 hours apart). The treatment group had a rate of 77% of symptom resolution and 60% healed fissure, whereas the control group had 54% symptom relief and 32.8% healed fissure, a significant difference. The study was able to avoid a high rate of headache reported in other studies, by advising endoanal application, which causes the nitroglycerin to go through first pass metabolism. No severe adverse effects were reported, however common complaints include “perianal erythema, colicky abdominal pain, and unexplained crying or nervousness” (Joda & Al-Mayoof). Negative aspects of this treatment include tachyphylaxis which necessitates constant dose increases in some patients, as well as, irritation to the site in three patients, which is thought to be the result of increased soiling from sphincter relaxation or from the ointment itself.  Other concerns include that the long treatment time and invasive application may limit compliance. 

Pediatric Anal Fissure