How to use nitroglycerin ointment?

Hi all,

I'm new to the forum but have been suffering with an anal fissure for the past 4 weeks. It's what I assume is your typical anal fissure, complete with the insane "like passing broken glass" pain and bleeding during every bowel movement. At times, following a bowel movement, it feels like my sphincter is still pushing uncontrollably like I'm still having a bowel movement, and there's an associated highly uncomfortable throbbing pain that lasts through the entire day (I guess this is the famous muscle spasm that comes with fissures).

Anyhow this thing has completely taken over my life now. I'm terrified of having any bowel movement, and I've just gone 48 hours without eating a single thing out of that fear. I'm 5'8" and only weigh 120 lbs. after all the weight I've lost recently, so needless to say, I can't go on like this much longer.

My doctor doesn't know much about fissures. At first he just gave me hydrocortisone suppositories, which didn't have any impact at all. Last week I managed to talk him into prescribing me some 0.2% nitroglycerin ointment (I think mixed in aloe vera gel to create the compound). He'd never heard of other treatments like botox injections or topical nifedipine so I may try to see a colorectal surgeon for information on those alternatives. My doctor did say that he can refer me for LIS, but that was the only other option he knew of. I'm quickly getting to the point where I'd happily opt for LIS, but would like to give the conservative stuff a try first.

So for now I'm trying the 0.2% nitroglycerin. My question is: how exactly am I supposed to apply it? Is it enough to apply around the outside of the anal area? Or do I actually need to put the ointment inside the anus on the fissure itself?

I don't know exactly where my fissure is located, and putting it inside the anus right now would cause great discomfort. I was on a high fiber diet with lots of salads and fruit as well as Miralax once a day, and it ended up giving me bad diarrhea, which was actually worse than constipation when it came to the fissure. So I've had a temporary setback and am waiting for the crazy spasms and throbbing pain to calm down before I can entertain any thought of putting ointment inside. But if inside is where it needs to be, then so be it. Anyway, any advice you all can offer on how to properly use the nitroglycerin would be most appreciated. My doctor seems to have no clue

Thanks in advance and sorry for the huge post.

you will need to apply the ointment on the fissure it self. If you are not too sure on where it is. Just apply it around the cornhole. Do not eat too much fiber or you will end up hurting your self further more. Water is probably your best bet and avoid eating sharp food ( popcorn, chips etc)

DOH! I was guessing maybe I'd have to put the ointment directly on the fissure. That one could be challenging as I think my fissure may be one of the kinds that's slightly further up (speculating on this as I don't feel anything right around the anus), so it's tough to reach.

Does anyone know of any ummm "tools" that can be purchased to assist in the ointment application process? I've heard of people using Q-tips but that seems like it would be hard to control, and could possibly leave some cotton behind?

No, actually, the ointment only needs to be put just inside the anus, it is not for direct healing of the fissure but indirectly, by setting up conditions for normal blood flow withing the anal canal, so it is not to be applied directly to the fissure (to my knowledge). TMWT's advice about the hard or sharp-edged foods is a very good one, peanuts, for example, would be a food to avoid (unless boiled)....

They gave me a "tool" to use with my ointment that was long and rigid. I ended up using a rounded "tool" that I was given with my Anusol ointment for hemmroids, and that "tool" worked extremely well once I was able to relax and not fear the insertion (because of pain). I was told by my Mayo doc to get the ointment up into the canal at least 1 cm.

Thanks guys! I have an applicator tip kind of thing from a tube of Anusol hemmorhoid cream and will try that. My anal area is super sore all the time, so getting it in there probably won't be comfortable, but the tool is pretty small so I think I can manage. Hopefully this at least gives some kind of improvement, the pain is getting to be unbearable. Thanks again!

Does it just say, "apply to affected area" on the tube?

Kim wrote:Does it just say, "apply to affected area" on the tube?

Yep it just says "apply to affected area 3 times daily". The actual ointment is something called "0.2% nitroglycerin in aquaphor ointment".

I put it on a plastic applicator this morning but am unsure of exactly how much got inside the anus. In the past I could tell by the side effects (a throbbing headache that comes on quickly and subsides quickly) but I don't think I get headaches from nitro anymore (they stopped after the first day or two of using it), so it's hard to say if it got where it needed to be.

Should add that I'm in the US, so the ointment bottle basically says whatever my doctor wrote in the prescription, since the 0.2% is custom compounded by the pharmacy. My doctor doesn't seem too knowledgeable about fissures (he claims that they just go away with use of hydrocortisone suppositories and fiber) so I don't think I'd trust his instructions too much to be frank.

Run to the closest CRS! I would not even bother going back to your doctor!

as for the cream, the further you get the cream in... the better!

NG, in the future, could you just determine if you got it in there by seeing the syringe empty, and maybe wiping yourself to show none had made it outside?

Hydrocortisone is really not something to use for fissures, as over time they thin the membrane....need I say more? I agree with Gahgah, now that you have a referral, you can use it (maybe once you have determined if the nitro is working or not)

How did things go today pain-wise?

Thanks, guys, I've been doing just that, trying to get the nitro in as much as possible and wiping to check if I was able to. It took a little bit to get the hang of using the syringe effectively but I think I've got it now.

Today's pain was pretty bad, unfortunately, had a large hard stool this morning with bleeding and it feels like there's "unfinished business" so now I'm absolutely dreading the rest of the day. Maybe I shouldn't have gotten brave and stopped the stool softeners, it seems that I can't find any middle ground between hard stools and watery acidic ones. All I ate yesterday was a piece of fish and some cereal, too, makes me worried to eat anything at all today.

Still got my fingers crossed, but gotta admit that it's a bit discouraging at the moment.

Please make sure you are drinking lots of water! If you are having hard stools still you really need to stay on the softner....my opinion, you just need to find the right one that isn't too much.

Macy is right. Stool softeners are your first line of defense with AF. Let's not be stopping the softeners, but it may be a trick finding the right one. Did you ever get the liquid colace and give it a try?

I actually didn't find the liquid Colace. I checked several stores and for some reason, none of them carried the liquid version of docusate sodium.

The Miralax worked great for me, but a full dose make things watery. So I think today I'm going to try a half dose and see what happens.

Just applied some nitro and am off to work now, throbbing headache, sore bum and all :-) Going to keep the eating to a minimum and overdose on water today!