Abstract
Background
Chronic anal fissures (CAFs) rarely heal with conservative management. Because they are associated with strong anal sphincter tone, most treatment aim to reduce anal pressure. Although infections can cause fissures, as can traumatic injury to the anal canal, antimicrobial treatment is not recommended. In a previous study, we reported identifying a wide spectrum of pathogenic microorganisms in the bases of CAFs, anaerobic bacteria being present in half the cases. We postulated that microbial colonization delays healing of CAF and aimed to determine whether decreasing the bacterial load with topical antibacterial treatment accelerates fissure healing.
Methods
We cultured fecal samples and swabs from the bases of CAFs in 103 patients. Patients in whose samples anaerobic bacteria were identified (47 patients) were then invited to participate in a prospective randomized clinical trial comparing topical metronidazole with conventional treatment. The primary endpoint was fissure healing confirmed on anoscopy. Secondary endpoints of maximum pain on defecation assessed by visual analog scale, maximum anal resting pressure, and rectal pH were recorded on entry and at 10, 21, and 28 days.
Results
The CAFs were colonized by mixtures of gram-positive/gram-negative anaerobic bacteria or gram-negative aerobic monocultures. Patients with anaerobic bacteria in their swabs who received topical metronidazole treatment experienced rapid relief of pain and anal sphincter spasm along with enhanced fissure healing (95.6 % healing rate compared with 70.8 % in the control group, p = 0.048).
Conclusion
Topical antimicrobial treatment can be effective in patients with CAF provided the relevant microorganisms are correctly identified.
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Conflict of interest
NMG, EAM, YL, VNB, LFT, and VAB declare that they have no conflict of interest.
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The authors declare that the study was performed in a manner to conform with the Helsinki declaration of 1975, as revised in 2000 and 2008 concerning human and animal rights, and the authors followed the policy concerning informed consent as shown on Springer.com. All patients gave written informed consent for participation in the study.
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Grekova, N.M., Maleva, E.A., Lebedeva, Y. et al. The effects of topical application of metronidazole for treatment of chronic anal fissure: A randomized, controlled pilot study. Indian J Gastroenterol 34, 152–157 (2015). https://doi.org/10.1007/s12664-015-0559-2
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DOI: https://doi.org/10.1007/s12664-015-0559-2