Annals of Coloproctology

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Original Article

The importance of topical metronidazole in the treatment of acute anal fissure: a double-blind study controlled for prospective randomization: Tuba Mert; Ann Coloproctol. 2023;39(2):131-138. Published online January 18, 2022; DOI: https://doi.org/10.3393/ac.2021.00675.0096

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6 Web of Science
9 Citations

Purpose
Acute anal fissure, a disease characterized by severe pain in the anorectal area, reduces quality of life and becomes chronic absent appropriate treatment. More recently, anaerobic infections have been noted as contributive to etiopathogenesis. This study investigates topical metronidazole’s effect in the treatment of acute anal fissure.
Methods
Our prospective randomized controlled double-blind study included 2 groups of 100 patients older than 18 years from our General Surgery Clinic with anal fissure complaints for less than 8 weeks. Topical diltiazem treatment was started in group 1, and topical diltiazem and metronidazole treatment in group 2. Pain levels were evaluated by the visual analogue scale (VAS) score, and recovery status was evaluated by physical examination findings ab initio and at the 1st, 4th, and 6th weeks. VAS score levels, demographic, clinical, and recovery status were then compared.
Results
There was no difference between the groups as to age, sex, pain on defecation, bleeding, constipation, and duration of pain, bleeding and constipation (P>0.05). From week 1, fissure epithelialization and healing rates were higher in group 2 (P<0.001); group 2 VAS score levels were lower than in group 1 (P<0.001) and achieved by group 1 only in week 4 (P=0.073).
Conclusion
Adding topical metronidazole to treatment reduces the duration and severity of pain, shortens healing time, and increases the healing rate.

Citations

Citations to this article as recorded by

A comparative study between combination of topical metronidazole and diltiazem vs diltiazem alone in treatment of acute anal fissure
Abhishek Jain, Rafat Khan, Nitin Garg
International Surgery Journal.2025; 12(3): 350. CrossRef
Search for bacterial biofilms in the chronic anal fissure (descriptive study with in-depth visualization)
M. A. Ignatenko, A. A. Ponomarenko, M. V. Zhurina, N. A. Kostrikina, E. E. Zharkov, Yu. A. Nikolaev, A. R. Melkumyan
Koloproktologia.2025; 24(3): 95. CrossRef
Efficacy of local metronidazole with glyceryl trinitrate versus topical glyceryl trinitrate alone in the treatment of acute anal fissure: a randomized clinical trial
Hesham M. Elgendy, Ahmed AbdelMawla, Ahmed F. Hussein
The Egyptian Journal of Surgery.2024; 43(1): 304. CrossRef
Belgian consensus guideline on the management of anal fissures
P Roelandt, G Bislenghi, G Coremans, D De Looze, M.A. Denis, H De Schepper, P Dewint, J Geldof, I Gijsen, N Komen, H Ruymbeke, J Stijns, M Surmont, D Van de Putte, S Van den Broeck, B Van Geluwe, J Wyndaele
Acta Gastro Enterologica Belgica.2024; 87(2): 304. CrossRef
Avances terapéuticos en el abordaje de las fisuras anales: explorando la sinergia entre Farmacología y Nanotecnología
Carlos Ostwaldo Pazmiño-Chiluiza, María Luisa González Rodríguez
Ars Pharmaceutica (Internet).2024; 65(4): 409. CrossRef
Local plus oral antibiotics and strict avoidance of constipation is effective and helps prevents surgery in most cases of anal fissure
Pankaj Garg, Vipul D. Yagnik, Kaushik Bhattacharya
Annals of Coloproctology.2023; 39(2): 188. CrossRef
COMPARATIVE STUDY ON THE EFFICACY OF TOPICAL METRONIDAZOLE, TOPICAL NITROGLYCERINE, AND TOPICAL DILTIAZEM IN THE MANAGEMENT OF CHRONIC ANAL FISSURE
PURSHOTAM DASS GUPTA, FAHAD TAUHEED, ANURAG SARASWAT, Karthik P
Asian Journal of Pharmaceutical and Clinical Research.2023; : 141. CrossRef
The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure
Antonio Brillantino, Adolfo Renzi, Pasquale Talento, Francesca Iacobellis, Luigi Brusciano, Luigi Monaco, Domenico Izzo, Alfredo Giordano, Michele Pinto, Corrado Fantini, Marcello Gasparrini, Michele Schiano Di Visconte, Francesca Milazzo, Giovanni Ferrer
BMC Surgery.2023;[Epub] CrossRef
Comparative Efficacy of Topical Metronidazole and Glyceryl Trinitrate Versus Topical Glyceryl Trinitrate Alone in the Treatment of Acute Anal Fissure: A Randomized Clinical Trial
M Hasaan Shahid, Sidra Javed, Saryia Javed, Anwar Zeb Khan, Adeel Kaiser, Reda H Mithany
Cureus.2022;[Epub] CrossRef

Review

Benign proctology

Metronidazole in the Management of Post-Open Haemorrhoidectomy Pain: Systematic Review: Angelina Di Re, James Wei Tatt Toh, Jonathan Iredell, Grahame Ctercteko; Ann Coloproctol. 2020;36(1):5-11. Published online February 29, 2020; DOI: https://doi.org/10.3393/ac.2020.01.08

7,150 View
166 Download
8 Web of Science
7 Citations

Abstract PDF

Purpose
Open haemorrhoidectomy is associated with significant postoperative pain. Metronidazole is commonly prescribed in the postoperative period as an adjunct to analgesia in pain management.
Methods
In our systematic review, studies were identified using PubMed/MEDLINE, Embase/Ovid and Cochrane Register of Controlled Trials databases. Studies were included if they were randomised controlled trials (RCTs) involving interventions with oral metronidazole at any dose over any time period. The primary outcome was pain score (visual analogue scale, VAS) after open haemorrhoidectomy. Secondary outcomes included time to return to normal daily activities, additional analgesia usage, and postoperative complications.
Results
Of 14 RCTs reviewed, 4 met inclusion criteria and were selected. The studies comprised 336 study subjects and 169 subjects were randomised to metronidazole while 167 were in the control group. There was a significant reduction in VAS across all time points, with maximal reduction seen on day 5 posthaemorrhoidectomy (mean difference, -2.28; 95% confidence interval, -2.49 to -2.08; P < 0.001). There was no difference in incidence of complications (P = 0.13). The Cochrane Risk of Bias Tool showed 3 of 4 of the studies had a risk of bias.
Conclusion
Metronidazole may be associated with decreased pain but there is insufficient evidence from RCTs to provide a strong grade of recommendation. Further RCTs are required.

Citations

Citations to this article as recorded by

Hemorrhoidal Disease
Jean H. Ashburn
JAMA.2025; 334(17): 1541. CrossRef
Role of antibiotics in Milligan-Morgan hemorrhoidectomy for Grade III to IV Hemorrhoids: A randomized clinical trial
Jiali Liu, Lei Lv, Hai-hua Qian, Ping-Liang Sun, Dan Zhang
Asian Journal of Surgery.2024; 47(1): 169. CrossRef
Topical metronidazole after haemorrhoidectomy to reduce postoperative pain: a systematic review
Chiara Eberspacher, Domenico Mascagni, Stefano Pontone, Francesco Leone Arcieri, Stefano Arcieri
Updates in Surgery.2024; 76(4): 1161. CrossRef
Conventional Excisional Haemorrhoidectomy versus Transanal Haemorrhoidal Dearterialization for Haemorrhoids: A Systematic Review and Meta-Analysis
Juliana Jee, Lauren Vourneen O’Connell, Ishapreet Kaur, Shaheel Mohammad Sahebally
Digestive Surgery.2024; 41(4): 204. CrossRef
Strategies to Reduce Post-Hemorrhoidectomy Pain: A Systematic Review
Varut Lohsiriwat, Romyen Jitmungngan
Medicina.2022; 58(3): 418. CrossRef
Topical Versus Oral Metronidazole After Excisional Hemorrhoidectomy: A Double-Blind Randomized Controlled Trial
Weisi Xia, Ahmed W.H. Barazanchi, Wiremu S. MacFater, Andrew D. MacCormick, Darren Svirskis, Tarik Sammour, Andrew G. Hill
Diseases of the Colon & Rectum.2022; 65(11): 1362. CrossRef
Treatment of Hemorrhoid in Unusual Condition-Pregnancy
Hyo Seon Ryu
The Ewha Medical Journal.2022;[Epub] CrossRef

Randomized Controlled Trial

Preventive Effects for Wound Infection of Intra-incisional Metronidazole Infiltration Preoperatively in Appendectomy.: Park, Bu Il , Kim, Byung Seok , Moon, Duk Jin , Park, Ju Sub; J Korean Soc Coloproctol. 2000;16(6):356-359.

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21 Download

Abstract PDF: PURPOSE
The aim of this prospective study was to evaluate the effect of metronidazole for wound infection by using intra-incisional infiltration before appendectomy.
METHODS
From January to May 2000, 176 patients with acute appendicitis received appendectomy. All patients were randomly divided into two groups. Group I (n=50) was the treatment group and group II (n=126) was the control group. After anesthesizing the patients of group I, 7.5 mg/kg of metronidazole was injected into subcutaneous tissue and muscle. All patients of group I and II were given intravenous injection of cephalosporin and intravenous or intramuscular injection of aminoglycoside.
RESULTS
In the 50 cases of group I, the rate of wound infection was 2% and the rate of wound infection in the 126 cases of group II was 4.8%. The rate of anaerobic bacteria of organisms cultured from wound of patients with infection was 0% in group I and 33% in group II. The statistical analysis using chi-square test was not significant (p=0.676) but the rate of wound infection was reduced, especially in infection caused by anaerobic bacteria.
CONCLUSIONS
The rate of wound infection was not significant statistically but it was reduced after intra-incisional infiltration of metronidazole. Therefore we suggest that this method can be one of methods that reduce the rate of wound infection after appendectomy.

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