Nitroglycerin [glyceryl trinitrate] is less costly than lateral internal sphincterotomy as a first-line treatment for chronic anal fissures, while offering comparable efficacy, according to a new study.1The analysis could further encourage the move from surgery to pharmacology in this common and painful condition. Chronic anal fissure arises from hypertonia of the internal anal sphincter. Alleviating hypertonia increases blood supply to the sphincter, promoting fissure healing. Although sphincterotomy is often effective, the operation can lead to complications, particularly incontinence.2The increasing recognition of the morbidity associated with lateral internal sphincterotomies helped drive management of chronic anal fissures from surgery toward pharmacological interventions, such as nitroglycerin ointment, over the last decade or so. Indeed, the number of lateral internal sphincterotomies performed in the UK and funded by the National Health Service (NHS) almost halved from 10 000 to 5500 procedures between 1996/1997 and 1999/2000.