When I first started practice, I had the privilege to serve in the small town of Bryson City, North Carolina, the southern wilderness entrance to the Great Smoky Mountains National Park. While there, one of the older surgeons taught me about using topic nitroglycerin ointment to cure chronic anal fissures. Now, thirty years later, it’s an officially approved medication.
The US Food and Drug Administration (FDA) has just approved nitroglycerin ointment 0.4% (Rectiv, ProStrakan Group) for the treatment of moderate to severe pain associated with chronic anal fissures.
Medscape reported, http://www.medscape.com/viewarticle/745118 “The ointment will be the only FDA-approved prescription product for patients with this condition, according to the company.”
The company “expects Rectiv to be available in the United States in the first quarter of 2012.”
Here’s what I wrote about this in 1981 in my book, Bryson City Tales: Stories of a doctor’s first year of practice in the Smoky Mountains:
“Son,” Mitch said, “he’s only had this three weeks. Can take months to heal. I don’t hardly ever take them to the OR before the fissure’s been there three months—less’n there’s an abscess. But come to think of it, bet I haven’t had one in OR in a dozen years since Dr. Bacon taught me the ol’ nitroglycerin trick.”
The ol’ nitroglycerin trick? My mind was racing through mental medical file after medical file but coming up empty. Fortunately, Dr. Mitchell didn’t ask me to reveal my ignorance. This was to be yet another case where my first professors in the world of real-life medicine would teach me something that wouldn’t be published in the medical literature for another dozen years or more.
“It’s really simple,” Mitch explained. “The older docs have been using this technique forever. It used to be more difficult to formulate, because Doc John had to keep the nitroglycerin in a cool, dark corner of the pharmacy. But when they came out with the premixed nitroglycerin ointment a few years back, it sure made things easier.”
“How in the world does it work? Does it work?”
“Like I said, son, I haven’t taken a chronic anal fissure to the OR since I started using the stuff. I suspect the nitroglycerin increases the blood flow to the area, same way it increases blood flow to the heart during an attack of angina. That helps the heal- ing. But it also seems to have a pain-relieving effect. Not rightly sure how it does that, but folks claim it works. It’s sure cheaper and easier than surgery.”
“So how do you prescribe it?”
“Simple, son, simple. Just prescribe anal nitroglycerin, and Doc John’ll mix it up for ya. He’ll fill a four-ounce tub with the stuff, and then instruct the patient to apply a pea-sized dab to the sore area four times a day and after each bowel movement. When Hal’s feeling better, he can decrease to three times a day, and, when better yet, he can decrease to twice a day. Let him know it can take up to eight weeks for the fissure to heal com- pletely. Now if it’s not healed in eight weeks, then we can consider operating.”
“Anal nitroglycerin!” I mused. “Why, I never . . .”
“Yep.” Mitch got that glint in his eye and the wry smile that preceded some sort of quip or joke. “I call this condition ‘anal angina.’ ”
Great name! I thought, as he went chuckling into an exam room to see his next patient.
Hal was delighted with the suggestion. “Actually, Doc,” he asserted, “done heard of that from ol’ Calvin Johnson when I was up fixin’ some pipes at his place. Said it worked like a charm for him. Don’t know why we didn’t think of that before.”