Hello everybody, I'm new here. Will introduce myself later today in the right section, as I'm a bit let's say shocked from this scientific study I just came across.
I've had a fissure since January, I was able to cicatrize it keeping my stool watery thanks to magnesium citrate (my proctologist literally said "no fissure here", you're fine), but then at the first "harder" trip to the bathroom the fissure used to reopen, so the agony was back to square one. I have a LIS scheduled in 10 days, but today I stumble across this scientific study (you'll find a link to it below) which explains how long lasting fissures have a base of infection that keep them "alive";
"

As of today, chronic fissure-in-ano is considered a non-infective pathology and antibiotics have no role in its management. However, during the last decade, evidence is emerging to the contrary. 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]. However, this relief was not sustained if constipation was not strictly avoided. Subsequently, in 2014, it was shown that local application of antibiotics cream (ornidazole with or without povidine-iodine) for 3 months in addition to the above regimen (a short course of oral antibiotics plus avoidance of constipation, local application of Diltiazem gel was recommended if anal sphincter spasm was present) sustained the symptomatic benefits achieved and helped to cure the fissure in up to 90 % of patients"

Now, this confuses me a little bit. We've been told antibiotics are useless for this condition unless a fissure gets infected and an abscess develops. This study seems to prove all of this wrong, trying to say that almost everybody who is dealing with a long lasting fissure should try the antibiotic treatment (both systemic and local, as the study mentions) as it would drastically improves the symptoms, which can only be a positive thing.

What do you guys think about this approach? No doctor ever talked to me about this, my guess is most doctors aren't that updated, probably. I'm in pain (need to keep my stool watery otherwise the pain knocks me out all day) but in all honesty, I would gladly avoid getting cut and messed up "down there", if a simple course of antibiotic is what's needed to see an improvement.



Here is the link to the study, I would love to know your opinion regarding this, as I'm a bit confused right now. What if in 15/20 years this "infective theory" gets approved worldwide among proctologists and LIS and other kind of fissures/related surgeries get declared "outdated"? Since LIS can potentially damage my anus permanently, I would make sense to try all the available alternatives, even if they're "immature".





LINK: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4848217/

Interesting find! I can imagine that you have (more) doubts about surgery when you read something like this. It still looks like mostly unexplored territory to me though.

The first reference is anecdotal evidence about the successful use of povidone iodine (Betadine 10%) in 3 persons. Honestly, it just looks too good to be true. All the symptoms settled after only 1-5 applications. The other studies referenced don't seem to be published anywhere (online).

I did however find a few studies testing a local antibiotic as a treatment of acute and chronic anal fissures. I don't have access to the latter study (2018), but its results are briefly discussed and mentioned in the more recent study of acute fissures.

Karapolat B. Could local antibiotics be included in the treatment of acute anal fissure?. Turk J Surg. 2018;34(4):286–289. Published 2018 Sep 11. doi:10.5152/turkjsurg.2018.3988

There are some serious limitations (small sample sizes, etc.) of these studies and I can see why it's not part of the standard treatment at the moment, but I think it's definitely worth discussing with your CRS. Maybe (s)he is willing to give it a try.

Ani wrote:Interesting find! I can imagine that you have (more) doubts about surgery when you read something like this. It still looks like mostly unexplored territory to me though. The first reference is anecdotal evidence about the successful use of povidone iodine (Betadine 10%) in 3 persons. Honestly, it just looks too good to be true. All the symptoms settled after only 1-5 applications. The other studies referenced don't seem to be published anywhere (online). I did however find a few studies testing a local antibiotic as a treatment of acute and chronic anal fissures. I don't have access to the latter study (2018), but its results are briefly discussed and mentioned in the more recent study of acute fissures. Karapolat B. Could local antibiotics be included in the treatment of acute anal fissure?. Turk J Surg. 2018;34(4):286–289. Published 2018 Sep 11. doi:10.5152/turkjsurg.2018.3988 There are some serious limitations (small sample sizes, etc.) of these studies and I can see why it's not part of the standard treatment at the moment, but I think it's definitely worth discussing with your CRS. Maybe (s)he is willing to give it a try.

Hello Ani, thanks for replying. Your comment was extremely useful, so thank you for that!
This "antibiotics story" appears to be extremely interesting if you ask me. We know anal fissures are extremely common, and most people get fissures without even noticing them, because of how fast the cicatrization problem is. Then there are those who need conservative treatments (creams) and in the end, those unlucky ones who have no choice but surgery. Could bacterias be making all the differences in these different "grades" of anal fissure? I feel like future anal fissure treatments (let's say in the next 10 years) will be extremely different from now, and won't probably even need surgery. I am no doctor, but bacterias could very well explain the problem. Given the region of the body where fissures occur, this is making even more sense, if you think about it.

For those interested in the topic that just found this post of mine;

This study was made and published by an Indian colon proctologist, and it has been published in an Indian surgery journal as well. I have found the name and the email address of the doctor, I'm now going to contact him and ask him more informations, as I feel this could very well be a revolution, and hopefully same a lots of butts from damn surgery!
Fingers' crossed. Will keep you updated.

ap093 wrote:

Ani wrote:Interesting find! I can imagine that you have (more) doubts about surgery when you read something like this. It still looks like mostly unexplored territory to me though. The first reference is anecdotal evidence about the successful use of povidone iodine (Betadine 10%) in 3 persons. Honestly, it just looks too good to be true. All the symptoms settled after only 1-5 applications. The other studies referenced don't seem to be published anywhere (online). I did however find a few studies testing a local antibiotic as a treatment of acute and chronic anal fissures. I don't have access to the latter study (2018), but its results are briefly discussed and mentioned in the more recent study of acute fissures. Karapolat B. Could local antibiotics be included in the treatment of acute anal fissure?. Turk J Surg. 2018;34(4):286–289. Published 2018 Sep 11. doi:10.5152/turkjsurg.2018.3988 There are some serious limitations (small sample sizes, etc.) of these studies and I can see why it's not part of the standard treatment at the moment, but I think it's definitely worth discussing with your CRS. Maybe (s)he is willing to give it a try.

Hello Ani, thanks for replying. Your comment was extremely useful, so thank you for that!
This "antibiotics story" appears to be extremely interesting if you ask me. We know anal fissures are extremely common, and most people get fissures without even noticing them, because of how fast the cicatrization problem is. Then there are those who need conservative treatments (creams) and in the end, those unlucky ones who have no choice but surgery. Could bacterias be making all the differences in these different "grades" of anal fissure?

I'm (also) just a layperson, but I can imagine the possibility of different causes (and treatments) of fissures.

High anal resting pressure and/or spasms -> Diltiazem, Botox, LIS, etc.
Infection -> Antibiotic treatment.
Fissure due to contipation/IBD -> Treatment directed at main cause.

I feel like future anal fissure treatments (let's say in the next 10 years) will be extremely different from now, and won't probably even need surgery. I am no doctor, but bacterias could very well explain the problem. Given the region of the body where fissures occur, this is making even more sense, if you think about it.

I certainly hope that the treatment of fissures will be different in the future, because the treatment options at the moment are a little bit dissatisfying and surprisingly limited for a disease that's pretty common and can have major effect on your daily life.

There are a few threads on Reddit discussing anal fissures, hemorrhoids, and bacteria. They conclude that your immune system is normally good enough to keep the 'bad' bacteria at bay. Although I can imagine that a reduced blood flow (due to high resting pressure) can have a negative impact on your immune system down there.

Having a fissure certainly made me a bit of a germophobe when it comes to my butt. Especially after reading stories of fissures becoming fistulas.

Hello everybody, I would really recommend you guys keep checking this post out because what I'm finding is truly shocking and kind of unbelievable. The studies I'm going to mention and link here below where conducted at the St. Mark's Hospital in London, which is an hotspot for anal diseases and research. Here you go;

CASE #1

"A 38-year-old man, who had no other medical problem, suffered from three episodes of acute fissure over a period of two weeks. Clinical examination confirmed the presence of an acute posterior midline anal fissure. The patient was treated with two applications of topical povidone iodine (Betadine ointment 10%, Molnlycke Health Care, Bedfordshire, UK). His symptoms settled, and the subsequent review revealed no recurrence at one year after treatment."


CASE #2

"A 48-year-old healthy man was diagnosed with a recurrent fissure-n-ano of one year's duration. The patient was initially given lactulose and nitroglycerine for three months. However, his symptoms failed to improve and a lateral sphincterotomy was recommended. On clinical examination, the patient was found to have a single posterior midline fissure. After repeated application of povidone iodine ointment 10% twice a day for five days, all his symptoms resolved. At the one-year follow-up, the patient remained symptom free."


CASE #3

"An eight-month pregnant woman with severe perianal pain was diagnosed with an acute fissure-in-ano. It was impossible to conduct a digital rectal examination in this patient. After one application of povidone iodine ointment at bedtime, all her symptoms settled. The patient's review at one year revealed no sign of recurrence."


FINAL CONSIDERATIONS

"'We do not know the mechanism of action of povidone iodine in fissure-in-ano. It may be the bactericidal, lubricating or some other unknown effects in povidone iodine, or a combination of factors present in the povidone iodine ointment. We had used povidone iodine ointment rather than the solution as the former was greasy and water soluble. A pilot study is currently underway to prove the effectiveness of povidone iodine in the treatment of fissures. If it is shown to be beneficial, then a prospective randomised controlled trial would be required to compare its efficacy against topical nitroglycerin, calcium channel blockers, botulinum toxin and surgical sphincterotomy"

The results of experimentation sound absolutely shocking to me for two reasons;

1) These 3 patients with sever fissure pain and symptoms got better (symptoms free) in a super short period of time...the pregnant woman applied the ointment at bedtime, and the sever symptoms cleared up the following morning, which is like 7-8 hours! Incredible! Doesn't this sound almost the same of what happens when we catch a sore throat, or any other common bacterias-related sickness? We feel bad, very ill, but as soon as we stat of course of antibiotics, we usually get relief in just a few days! Other techniques such as Calcium channel blockers and nitro usually take WEEKS before patients see an improvement over their symptoms, but in this case the improvement is lightning fast. Can you imagine months/years of unnecessary fissure pain, when your symptoms could actually be controlled in a period of time such as just 5 days? Doesn't this shock you? It sure does shock me.

2) All 3 of the studies mention that all patients were still symptoms/fissure free one year later, which is absolutely incredible. Seems like a truly definitive therapy, that truly addresses the root causes of the problems.

Do you guys still feel like having a surgery and potentially risk "life-lasting" injuries, when therapies like this show amazing results in a shorter period of time than a week? I'll be calling the Saint Mark's Hospital of London tomorrow, and will ask informations about the equipe who conducted these experiments, just to see if I can replicate this therapy at home. This sounds absolutely intriguing to me, and If I can, I would gladly avoid getting surgery.

Feedbacks are super welcome, feel free to share your thoughts! I encourage you to do so!

I don't want to be a debbie downer, but 3 persons is an extremely small sample size and the success reported (after only on application!) look almost too good to be true. Similar to some of the anecdotal reports of different supplements, ointments and interventions in the anal fissure succes subforum.

That doesn't mean however that it can't work. Maybe they're on the right track and is this going to be the future of anal fissure treatment. We don't know. The infection hypothesis is certainly interesting and using povidone-iodine is maybe worth a try. It's available over the counter.

Even if it doesn't work, you can put your mind at ease knowing that you've tried everything before surgery. I'd discuss it with your CRS first though, maybe (s)he even had other patients who've tried this.

Keep up updated!

ap093 wrote:
Do you guys still feel like having a surgery and potentially risk "life-lasting" injuries, when therapies like this show amazing results in a shorter period of time than a week? I'll be calling the Saint Mark's Hospital of London tomorrow, and will ask informations about the equipe who conducted these experiments, just to see if I can replicate this therapy at home. This sounds absolutely intriguing to me, and If I can, I would gladly avoid getting surgery.

Feedbacks are super welcome, feel free to share your thoughts! I encourage you to do so!

ap093: What did you find out from the hospital?

So I've been stuck at where I am in terms of healing (from an acute-going-on-chronic fissure) for about a week. I feel like I've healed to 80-85%, but the last bit wouldn't budge. My internal hemmie (size of chickpea) seems to be complicating it a little bit. My stool is soft, I'm doing all the right things, but yet my fissure is not healing further, so I think bacterial infection might be a possible explanation.

My parents happen to be visiting from China and they brought some TCM(Traditional Chinese Medicine)-based ointment for me. I got in touch with the seller of this particular brand of ointment, which is from a TCM family. I described my situation to the TCM doctor, and she suggested I take Levofloxacin for a few days to counter possible infection and inflammation caused by bacteria (notes: Levofloxacin might have serious and damaging side effects; I rarely take antibiotics but based on past experience knew my body could handle it).

And then I saw this post, which made me want to try Levofloxacin even more. I took 500mg yesterday, and plan to take 250mg per day for another 5 to 7 days. Will report back how I feel.