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Ann Coloproctol > Volume 39(2); 2023 > Article
Garg, Yagnik, and Bhattacharya: Local plus oral antibiotics and strict avoidance of constipation is effective and helps prevents surgery in most cases of anal fissure
Dear Editor,
We read with great interest the article by Mert [1] outlining the importance of infection in etiopathogenesis and hence the efficacy of topical metronidazole in the treatment of acute anal fissures. We have been working on the same concept for the last several years [26] and would like to highlight a few pertinent points as per our experience with LOABAC (local plus oral antibiotics with avoidance of constipation) regimen to manage fissure conservatively.
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. A small proportion of patients (< 5%) experience a burning sensation after the application of povidone-iodine cream in whom this cream may be withheld.
Second, the addition of a short course of oral antibiotics covering gram-negative and anaerobes (ciprofloxacin and metronidazole) also increases the efficacy of this conservative management. In the presence of pain especially in the acute anal fissure, the local cream application is difficult and painful due to which the compliance of the patients falls significantly. Therefore, an addition of a short course (5 days) of oral antibiotics, by eradicating infection in anal fissure, gives much-needed immediate relief in pain and spasm. This results in the subsequent easier application of local antibiotics cream on anal fissure inside the anal canal.
Third, while outlining the inclusion criteria, the author defined acute anal fissure as an anal fissure present for less than 8 weeks, lesions limited to the epithelium on physical examination, and no findings suggestive of chronic anal fissure (such as skin tag in the anal region) [1]. Though the duration of the existence of anal fissure is taken as one of the criteria to differentiate acute from chronic anal fissure, it is prudent that the presence or absence of anal spasm should also be included as a main parameter [4]. Because the presence of spasm would require appropriate management for complete healing of the anal fissure. Therefore, like other chronic disorders, anal fissure should be categorized as acute anal fissure, chronic anal fissure, and acute-on-chronic anal fissure (Table 1) [4]. This classification takes both duration of existence of anal fissure as well as the spasm into consideration. Once this is done, the management of each category becomes quite clear and avoids unnecessary confusion [4].
The anal fissure should be classified based on the duration of onset of symptoms and clinically assessed anal tone (Table 1) [4]: acute fissure of < 6 weeks duration with high anal tone (spasm); chronic fissure of > 6 weeks duration with normal/low anal tone (no spasm); and acute-on-chronic fissure of > 6 weeks duration with high anal tone (spasm). The management of anal fissure in each category is outlined in Table 1.



No potential conflict of interest relevant to this article was reported.




Conceptualization: all authors; Formal analysis: all authors; Project administration: all authors; Methodology: all authors; Software: all authors; Supervision: all authors; Validation: all authors; Visualization: all authors; Data curation: PG, VDY. Investigation: PG. Writing–original draft: PG. Writing–review & editing: all authors. All authors have read and approved the final manuscript.

Table 1.
Proper classification of anal fissures and their treatment
Category of anal fissures Duration (wk) Spasm Creams for relieving spasm (diltiazem and nifedipine) Locala+oralb antibiotics Stool softeners Sitz bath
Acute <6 ++++ Yes Optional Yes Yes
Chronic >6 No Yes Yes No
Acute-on-chronic >6 ++++ Yes Yes Yes Yes

a Metronidazole+povidone-iodine cream.

b Ciprofloxacin+metronidazole, 5 days.


1. Mert T. The importance of topical metronidazole in the treatment of acute anal fissure: a double-blind study controlled for prospective randomization. Ann Coloproctol 2023;39:131–8.
2. Garg P. A simple novel concept to conservatively manage refractory spasm in acute fissure-in-ano: Defecation put on-hold temporarily (DePOT). J Family Med Prim Care 2020;9:5800–1.
crossref pmid pmc
3. Garg P. Should hemorrhoids and chronic anal fissure be treated as medical disorders? A rational way to move forward. Dis Colon Rectum 2019;62:e8.
4. Garg P, Lakhtaria P, Gupta V. Oral plus local antibiotics significantly reduce the need for operative intervention in chronic anal fissure: a novel finding. Indian J Surg 2018;80:415–20.
crossref pdf
5. Garg P. Editorial comment on “Could local antibiotics be included in the treatment of acute anal fissure?”. Turk J Surg 2018;34:349–50.
pmid pmc
6. Garg P. Local and oral antibiotics with avoidance of constipation (LOABAC) treatment for anal fissure: a new concept in conservative management. Indian J Surg 2016;78:80.
crossref pmid pmc pdf
7. Durai R, Razvi A, Hin PN. Novel use of povidone iodine in fissure-in-ano. Singapore Med J 2010;51:837–8.
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