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... 14 Grekova et al also documented that addition of topical metronidazole in those patients whose swab revealed presence of anaerobic bacteria, lead to rapid relief of spasm of anal sphincter and pain along with enhanced fissure healing (95.6 % healing rate compared with 70.8 % in the control group, p = 0.048). 15 In our study healing rate in participants receiving local antibiotic was 89.7% compared to that without antibiotic 75%. ...
... Findings of a pilot study documenting the advantage of local application of povidone-iodine solution in chronic anal fissures corroborates with that in our study. 15 Other authors have recorded the benefits of oral ciprofloxacin with or without metronidazole for a treatment period of 5 days by recording symptomatic relief in more than 90% cases with chronic anal fissures. 16 Further, the local application of ornidazole cream for 3 months in addition to oral antibiotics lead to a cure rate of 90%. ...
Acute anal fissure is a common and painful condition of ano-rectal region characterized by tear in the anoderm causing pain during defecation. Mainstay of its treatment is pharmacotherapy with lifestyle modification.
Current study was undertaken to evaluate the role of add-on local antimicrobial in recovery and relief of symptoms of acute anal fissure in comparison to local anesthetic and vasodilator without any antimicrobial.
It was a randomized, assessor-blinded, active-controlled clinical study in which data of 68 eligible participants were analyzed. Participants of both group received local lignocaine and nifedipine and the test group (Group B) received metronidazole ointment in addition. Healing was assessed by clinical examination and pain by Numeric Pain Rating Scale. Sample size was calculated based upon result of older pilot study and the proportion of recovery were assessed by Chi-square test.
After 6 weeks of treatment, 61 out of 68 (i.e., 89.7%) patients receiving add-on antimicrobial recovered completely compared to 75% of the comparator group. Reduction of pain and cessation of bleeding were also significantly better in patients receiving additional antibacterial.
Healing and symptom relief in acute anal fissure is better with addition of local antibacterial along with local vasodilator and anesthetic.
... First, for local application on anal fissure, the addition of povidone-iodine cream increases the efficacy of local metronidazole cream [4,7]. This is expected because unlike metronidazole which is effective against mainly anaerobes, povidone-iodine has an action against a broad spectrum of microorganisms which include aerobes (both gram-positive and gram-negative), fungi, protozoa, tubercle bacilli, viruses, and bacterial spores. ...
... This was demonstrated by decreases in the VAS scores at the end of weeks 2 and 4 of treatment. A review of the literature revealed that there was improvement in the symptoms in a pilot study involving local application of povidone-iodine solution in chronic anal fissure (12). Moreover, with oral ciprofloxacin and ornidazole that were used for a period of only 5 days, significant symptomatic relief was achieved in >90% of cases with chronic anal fissure (13). ...
Objective:
Acute anal fissure is a very common disorder of the anorectal region. Its most widely used treatment method is the medications given in addition to conservative therapies. The objective of the present study was to investigate the effects of local metronidazole use in the treatment of acute anal fissure on the symptoms and remission processes of the patients.
Material and methods:
This was a prospective, randomized, controlled clinical study conducted on 100 consecutive patients who presented to our clinic between March 2016 and March 2017 and who were diagnosed with acute anal fissure. Patients were randomly divided into two groups of 50 persons. Patients in Group 1 were given only 5% lidocaine pomade as a local anesthesia, and those in Group 2 were given 5% lidocaine pomade and metronidazole cream. Patients applied the medications topically to the anal margin 3 times per day for 4 weeks. Patients' demographic characteristics, such as age and gender, were recorded. All patients were invited for check-up at the end of weeks 1, 2, and 4 of treatment. The Visual Analogue Scale scores for pain and the healing status of their fissure by visual inspection, as well as any adverse effects of the drugs, were recorded. The results were compared statistically. A p-value <0.05 was considered significant.
Results:
The mean ages of the patients were 34.2±4.1 years in Group 1 and 36.6±3.8 years in Group 2. As a result of the statistical comparison of the Visual Analogue Scale scores, there was a statistically significant difference between the two groups at the end of weeks 2 and 4 (p=0.004 and p<0.001, respectively). In Group 1, 28 (56%) patients recovered, but no recovery was observed in 22 (44%) patients. In Group 2, 43 (86%) patients recovered, whereas 7 (14%) patients had no recovery (p=0.004).
Conclusion:
The topical antimicrobial treatment with metronidazole as an addition to the classical medical treatments in acute anal fissure is an effective and safe practice resulting in further reduction in pain and increased healing rate.
... In 2007, Pelta et al. found subcutaneous tract at the base of the fissure in almost all the patients and hypothesized sub-clinical infection as the reason for causing symptoms in chronic fissure-in-ano. In 2010, local application of povidine-iodine solution showed to improve symptoms in chronic fissure [1]. In 2012, it was demonstrated that a short course (5 days) of oral antibiotics (ciprofloxacin 500 mg plus ornidazole 500 mg) gave significant symptomatic relief in up to 90 % patients [2]. ...
Introduction
Anal fissure is one of the most common diseases of the anorectal region that is frequently encountered in surgical practice, equally affects both women and men. Acute anal fissures last shorter than 6 weeks. The American Society of Colon and Rectal Surgeons favors conservative management of anal fissure as the first line of treatment. A rectal ointment containing 0.2% glyceryl triturate (GTN) can be recommended to promote the healing of anal fissures and decreasing sphincter spasm. Metronidazole is a 5-nitroimidazole derivative antibiotic with a cytotoxic bactericidal effect particularly on anaerobic bacteria.
The purpose of the present study was to investigate whether local metronidazole antibiotic cream is effective and safe to use in reducing the symptoms and improving the healing process of acute anal fissure.
Patients and methods
This study was performed in Mansoura University Hospital, surgery outpatient clinic from the period of July 2022 till July 2023. This study was a single-blinded, randomized controlled trial.
Total 100 patients were included in this study and randomly divided into two groups, 50 patients in each group. First group (group 1) treated by combination of local metronidazole 10% with 0.2% GTN while the second group treated only with GTN.
Results
Anal pain were present in both group in all patients with acute anal fissure while constipation were 88% in group 1 and 76% group 2. To lesser extent itching, bleeding, and diarrhea were presented in both group.
Visual analog scale for pain intensity were equal in both groups at the time of first clinical examination. After 1 week and 1 month of treatment there were statistically significant difference between both groups thus the visual analog scale were lower in group 1 than group 2 (0.001 and <0.001, respectively).
Healing of acute anal fissure was assessed clinically at variable interval for all patients there is statistically significant difference between both group (0.004) as regard healing, first group showed earlier and faster healing and fewer number of nonhealing of the fissure at the end of follow up.
Conclusion
Adding local metronidazole 10% to the classic GTN treatment will improve the symptoms of acute anal fissure specially pain and discomfort and markedly accelerate healing process.
Anal fistula is an abnormal communication between the anorectum and the skin or a blind tract originating from the anorectum and causing recurrent sepsis [1].
Up to 40% patients with chronic fissure-in-ano require operative intervention. As of today, antibiotics, local or oral, have no role in the treatment of chronic fissure-in-ano. In a prospective study, fissure-in-ano was classified as follows: acute <6-week duration, chronic >6-week duration with normal/low anal tone, and acute-on-chronic >6-week duration with high anal tone. The resting anal tone was assessed clinically on an objective scale—DRESS score—the digital rectal examination scoring system. Local and oral antibiotics with avoidance of constipation (LOABAC) treatment was advocated for 6 months. For refractory cases, liquid paraffin and, for high anal tone, diltiazem cream along with sitz bath were prescribed. Non-responders underwent a MRI to look for fissure deepening (presence of sinus/fistula). Healing of fissure-in-ano was assessed by absence of pain, burning, itching, or spasm after defecation and absence of tenderness on per-rectal examination. Out of 109 fissure-in-ano patients recruited over 20 months, 90 (M/F—50/40) were finally included. Mean age was 37.6 ± 12.3 years. Conservatively managed, 86.7% (78/90) patients had significant relief and were cured without requiring any further intervention. Twelve out of ninety (13.3%) patients had no/minimal relief and underwent a MRI which revealed a fissure-sinus/tract in 10/90 (11.1%). MRI was normal in 2/90 (2%). Five out of ten patients with sinus underwent surgery (laying open of the sinus) and became alright subsequently. The rest of the five patients were lost to follow-up. In chronic fissure-in-ano, the regimen of local and oral antibiotics with avoidance of constipation significantly decreases the need for operative intervention.
Chronic anal fissure (CAF) is a painful tear or crack which occurs in the anoderm. The optimal algorithm of therapy for CAF is still debated. Lateral internal sphincterotomy (LIS) is a surgical treatment, considered as the 'gold standard' therapy for CAF. It relieves CAF symptoms with a high rate of healing. Chemical sphincterotomy (CS) with nitrates, calcium blockers or botulinum toxin (BTX) is safe, with the rapid relief of pain, mild side-effects and no risk of surgery or anesthesia, but is a statistically less effective therapy for CAF than LIS. This article considers if aggressive treatment should only be offered to patients who fail pharmacological sphincterotomy. Aspects of anal fissure etiology, epidemiology and pathophysiology are considered with their meaning for further management of CAF. A molecular model of chemical interdependence significant for the chemistry of CAF healing is examined. Its application may influence the development of optimal therapy for CAF. BTX is currently considered the most effective type of CS and discussion in this article scrutinizes this method specifically. Although the effectiveness of BTX vs. LIS has been discussed, the essential focus of the article concerns identifying the best therapy application for anal fissure. Elements are presented which may help us to predict CAF healing. They provide rationale for the expansion of the CAF therapy algorithm. Ethical and economic factors are also considered in brief. As long as the patient is willing to accept the potential risk of fecal incontinence, we have grounds for the 'gold standard' (LIS) as the first-line treatment for CAF. The author concludes that, when the diagnosis of the anal fissure is established, CS should be considered for both ethical and economic reasons. He is convinced that a greater understanding and recognition of benign anal disorders by the GP and a proactive involvement at the point of initial diagnosis would facilitate the consideration of CS at an earlier, more practical stage with improved outcomes for the patient.
The present study aims to evaluate and compare the efficacy of two nitrate gels, containing isosorbide-5-mononitrate (ISMN) or glyceryl trinitrate (GTN), in the therapy of chronic anal fissure.
The patients were randomly assigned to three groups: 0.1% ISMN gel (21 patients), 0.1% GTN gel (21 patients) and a placebo group (ten patients). The ethic committee of our hospital approved the protocol and informed consent was obtained from all participants. All patients underwent clinical examination, visual inspection of the fissure and anal manometry prior to and after therapy.
The chronic anal fissure was completely healed in 71% of the patients treated with ISMN, 67% with GTN and in 30% from the placebo group. One patient in the ISMN group reported mild headache. Three patients in the GTN group had anal burning.
Both topical nitrate treatments (ISMN and GTN) were effective for chronic anal fissures. The reduction of the anal pressure was slightly higher after ISMN treatment (28%) than the treatment with GTN (23%). However, the statistical difference was not significant (p>0.05).
Subcutaneous lateral internal sphincterotomy (SLIS) is an effective treatment for fissure in ano but carries a definite risk of incontinence. The aim of this study was to assess the efficacy and complications of SLIS in patients with chronic fissure in ano.
All patients presenting with a chronic anal fissure who underwent SLIS were entered into a prospective database. This is a review of these patients over 5 year's period (September 2002-2007). All operations were performed or directly supervised by a consultant colorectal surgeon. Short-term follow-up was at the first outpatient appointment (6 weeks postoperatively) and any impairment of continence was documented.
During the study period of 5 years, 96 patients underwent SLIS at our institution. Median patient age was 45 years (range 19-81). The median duration of symptoms was 65 days. No fissure failed to heal after SLIS. Minor complications were noted in five patients; 85% (82/96) attended the follow-up and out of these, 6% (5/82) reported early incontinence. One patient was incontinent to flatus, one to liquid and three to solid stool. After 12 weeks of follow-up, two patients were completely symptom free, one was incontinent to flatus and two were incontinent to liquid stool.
SLIS remains an effective treatment for chronic anal fissure. A small proportion of patients do suffer from faecal incontinence, which may be permanent in some cases. Careful patient selection and proper surgical training can reduce this risk.
A 50-year-old man developed numerous pustules and bullae on the trunk and limbs 15 days after anal fissure surgery. The clinicopathological diagnosis was iododerma induced by topical povidone-iodine sitz baths postoperatively. Complete resolution occurred within 3 weeks using systemic corticosteroids and forced diuresis.