Treatment of Anal Fissure with Botox

Botox (botulinum toxin type A) is widely used in the treatment of lines and wrinkles, including glabellar lines between the eyebrows, forehead lines, and crow’s feet. In addition to cosmetic use, Botox is also effective against a number of medical conditions. This includes blepharospasm (associated with dystonia), strabismus, excessive sweating (severe axillary hyperhidrosis), spasticity in cerebral palsy and spinal injuries, overactive bladder, cervical dystonia, and urinary incontinence (resulting from detrusor overactivity associated with neurologic conditions such as multiple sclerosis).

Due to its muscle relaxant properties, Botox is also suitable for the treatment of anal fissures. It acts in the muscles of the anus to decrease muscle tension. This helps to relieve pain and promotes blood flow to the fissure, allowing it to heal naturally. Botox is generally indicated for patients who respond inadequately to conservative treatments such as laxatives, a high fiber diet, and creams (e.g. diltiazem ointment and GTN rectogesic).

What are anal fissures?

Anal fissures are common and characterized by pain with bowel movements, itching, and bleeding. These symptoms can sometimes be serious and require medical attention. Anal fissures are typically caused by an open sore or small tear at the opening of the lining of the anus.

While anal fissures usually resolve themselves within a few weeks, some patients may experience chronic fissures, which can last up to 4 to 6 weeks. Some factors such as childbirth, diarrhea, passing hard stools or constipation can increase the risk of developing anal fissures. Anal fissures may occur comorbidly with another medical condition. In some cases, the cause of an anal fissure is unknown.

How effective is Botox in the treatment of anal fissures?

A study by Piccinni et al shows that botulinum toxin is safe and efficacious in the treatment of anal fissures. In fact, intrasphincteric botulinum toxin injections are recommended by the researchers as the first line treatment before surgery (e.g. sphincterotomy).

While effective, conventional treatments such as sphincterotomy can cause side effects such as incontinence. Although actual results may vary among individuals, most patients are able to find success with Botox. The average success rate for this procedure is as high as 70%. Keep in mind that some patients need to repeat the treatment to see results.

What happens before the procedure?

During the consultation, the surgeon will explain the procedure to the patient. As always, the surgeon will discuss the symptoms and address any questions and concerns the patient may have. The patient should be made aware of all the potential risks and only proceed with treatment if they find the risks acceptable.

Special preparation is not required for this procedure. Therefore, there are no diet restrictions before the treatment (patients are allowed to eat and drink as usual). Patients are advised to carry out their normal hygiene routine (e.g. bath or shower). 

What happens during the procedure?

The treatment will be performed in the outpatient clinic by a surgeon. The whole treatment typically takes several minutes to complete. No general anesthesia is involved in the procedure. Throughout the procedure, patients will remain awake. Botox for anal fissures is associated with minimal downtime. Most patients are able to drive and resume daily activities right after the procedure.

The patient must remove their lower clothes and lie down comfortably on their left side. Using an alcohol wipe, the surgeon will clean the area around the anus. Then, two Botox injections will be given into the sphincter muscle surrounding the anus. While this can cause slight discomfort, the procedure is extremely quick, and the uncomfortable sensation will not last long. A local anesthetic may be applied as needed to numb the treatment area.

What happens after the procedure?

Following the injections, the patient will dress and leave the clinic at their leisure. Alternatively, the patient may sit in the waiting room for a period of time before de[arting. As long as the patient is feeling well, there is no need for hospitalization.

The surgeon may prescribe oral pain medications like paracetamol to alleviate any soreness after the procedure. Botox takes effect over a period of several days. In general, the effects of Botox can last for up to two to three months, which is long enough for the anal fissure to heal.

In order to prevent straining, patients must ensure that their stools are soft after the procedure. They should take a doctor-prescribed laxative and include fiber in their diet.

After three months, the surgeon will call the patient to discuss their progress and schedule a follow up meeting. 

What are the risks and side effects of the procedure?

As with all surgical procedures, there is a risk of infection. Most commonly, patients will experience injection-related side effects, such as swelling and pain. Patients should be informed of all potential side effects that may occur as a result of undergoing Botox for anal fissures.