Rectogesic or an alternative? What surgeons weigh before choosing your fissure ointment

What exactly is Rectogesic?

Rectogesic is a brand name, not a new drug. Inside the tube is nitroglycerin, also called glyceryl trinitrate or GTN, at a strength of 0.4 % in an ointment made to be applied at the anal opening. It is the same molecule people with angina use, at a much lower dose and in a base designed for the anal canal.

What makes Rectogesic different from the other fissure ointments is its regulatory status. It is a licensed medicine: a factory-made product with a marketing authorization, a fixed strength, a patient leaflet and a stable shelf life. In the UK and across much of Europe, it is the product a family doctor can prescribe and any pharmacy can supply without special preparation. That is why it is the fissure ointment people search for by name, far more than diltiazem or nifedipine.

In the United States the comparable product is Rectiv, also nitroglycerin 0.4 %, licensed for the pain of chronic anal fissure. In Australia, Rectogesic is also sold; check the strength printed on your pack, because it may differ from the European product. For the drug itself, how it works and why it causes headaches, see our guide on Nitroglycerin ointment for anal fissure: does it work, and can you live with the headache? and the nitroglycerin page.

What does the Rectogesic leaflet tell you, and what does it leave out?

The leaflet is written for the drug, not for the fissure. It covers the essentials, and you should read it before the first dose. In plain terms, it tells you:

• What it is for: relief of the pain of a chronic anal fissure. Note the wording: pain relief is the licensed claim; healing follows when the sphincter stays relaxed long enough.
• How often: usually twice a day, about 12 hours apart, for up to 8 weeks. Follow the exact amount and duration on your leaflet and your doctor’s instructions; the pack includes a way to measure each dose.
• The main side effect: headache, which affects up to half of patients, plus dizziness or lightheadedness when standing up.
• Who should not use it: people taking sildenafil, tadalafil, vardenafil or riociguat, people with low blood pressure, and people with certain heart valve or heart muscle conditions.

What the leaflet cannot tell you is how to make the treatment work. Three points we add in clinic: use a finger cot or glove, because nitroglycerin crosses the skin of your fingertip; keep stools soft every single day, because a hard stool can reopen the tear whatever ointment you use; and do not stop at week 3 just because the pain is gone. The full routine is in How to apply anal fissure cream correctly: where, how much and when.

How does Rectogesic compare with diltiazem and nifedipine?

On healing, the three ointments are close. On tolerance and access, they are not. This is the comparison we walk patients through:

The evidence behind that table: the Cochrane review of non-surgical therapy found nitroglycerin healed 48.9 % of chronic fissures against 35.5 % with placebo, with about half of healed fissures recurring, and that calcium channel blockers matched it with fewer adverse effects. A systematic review of seven randomized trials and 481 patients found diltiazem and nitroglycerin equally effective, with diltiazem causing fewer headaches (risk ratio 0.39) and fewer recurrences (risk ratio 0.68). For a deeper look at all three drugs side by side, read Nifedipine, diltiazem or nitroglycerin: which fissure ointment should you choose?.

Who is Rectogesic a good choice for?

Despite the headache, Rectogesic remains a sensible first prescription for many people, and both the American (ASCRS 2023) and British (ACPGBI 2023) guidelines accept topical nitrates as first-line treatment for a chronic fissure. It tends to suit:

• People who need treatment without delay and live where diltiazem or nifedipine ointment is hard to get. A licensed product is on the pharmacy shelf; a compounded ointment may take days and costs more in some places.
• Patients seen first by a family doctor, who often prescribe what is on the national formulary before referring to a colorectal surgeon.
• People without migraine, low blood pressure or heart disease, who are more likely to tolerate the headache and complete the course.
• People who value a standardized product, with a fixed strength and a dosing aid, over a pharmacy-made preparation.

It is a poorer fit for people who already know they get bad headaches, those on erectile dysfunction pills, and anyone pregnant or breastfeeding; treatment choices in pregnancy are covered in Which anal fissure cream is safe in pregnancy and while breastfeeding?.

When should you switch from Rectogesic to a calcium channel blocker?

Switching is not a failure; it is often the right call. These are the situations in which we move a patient from Rectogesic to diltiazem or nifedipine:

1. The headache is still severe after the first week, or it makes you skip doses. Partial treatment is the most common reason a fissure stays open. The measures that soften the headache are listed in Side effects of anal fissure creams and how to manage them.
2. You start a medicine that cannot be combined with nitrates, such as sildenafil or tadalafil.
3. You feel faint, dizzy on standing, or have palpitations after applying it.
4. You stopped early because of side effects and the fissure came back. A fresh 6 to 8 week course with a better-tolerated ointment is reasonable.

What does not justify switching: a fissure that still hurts a little at week 2, or one that bled once after a hard stool. The ointment needs time, and stool control matters as much as the drug. If you completed 6 to 8 weeks correctly and the fissure is still open, changing ointments again rarely helps; the next steps are a botulinum toxin injection or a lateral internal sphincterotomy, discussed with a colorectal surgeon. See Four weeks on fissure cream and no better: what to check and what comes next before you decide, and All guides for the next step.

Where can you get Rectogesic, Rectiv or the alternatives?

All of these ointments need a prescription in the countries we cover. What changes is which product is ready-made and which must be compounded:

Availability and brand names change over time, so confirm with your pharmacist. Two safety rules apply everywhere: never use the stronger nitroglycerin ointment sold for angina on the anus, and always check the strength printed on the label. If you are using a pharmacy-made ointment, Compounded fissure cream: what it is, how to get one and why it doesn’t travel explains what to ask for.

When is the problem bigger than the ointment?

Rectogesic and its alternatives treat a typical fissure: a painful tear in the back or front midline of the anal canal that hurts with every bowel movement. They are not meant to cover other problems. See a doctor without delay if you notice:

If you are not sure you have a fissure in the first place, our symptoms page explains what fits and what does not.

Where does FISURIN fit?

FISURIN is not an alternative brand of Rectogesic: it contains no nitroglycerin. It is the cream our surgeons at Clínica Proctológica de Lima prescribe for chronic and post-operative fissures, combining nifedipine (a calcium channel blocker) with lidocaine in a water-based hydrogel and a written 6-week protocol. For patients who cannot tolerate the headache of nitroglycerin, it is one way to stay on a sphincter relaxant, but it still needs soft stools and the full course, and it cannot promise closure in every case. Today FISURIN is a magistral formula prepared under prescription in Peru and is not shipped abroad; FISURIN Hydrogel and FISURIN Relief are in preparation, with a waiting list by country. See what is inside FISURIN or how to get it where you live.