Treatment of Anal Fissure with Botox

Botox (botulinum toxin type A) is widely used in the treatment of lines and wrinkles such as glabellar lines between 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. Botox acts in the muscles around the back passage (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 fissure is a common condition characterized by pain with bowel movements, itching, and bleeding. These symptoms can sometimes be serious and require medical attention. Anal fissures are commonly caused by an open sore (e.g. ulcer) or a small tear at the opening of the back passage (lining of the anus). While anal fissures usually resolve themselves in several weeks, some patients may experience chronic fissures, which can last beyond 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 also 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 has shown 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 often cause side effects such as incontinence. Although actual results may vary among individuals, most patients are able to find success with Botox for anal fissures. In fact, the average success rate for the 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 about the symptoms and address any questions and concerns patients may have. The patients should be made aware of all the potential risks before receiving the treatment. Patients should only proceed with the treatment only 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). There is no need to perform a bowel preparation, but patients are advised to carry out their hygiene routine (e.g. bath or shower) as usual.

What happens during the treatment?

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.

Patients will be required to take off their lower clothes and lie comfortably on a couch 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?

After completing the injections, patients will be asked to get dressed and go home when they are ready. Alternatively, the patient may sit in the waiting room for a while before they leave. As long as the patient is feeling well, there is no need for hospitalization.

The surgeon may prescribe oral painkillers (such as paracetamol) to alleviate any soreness after the procedure. Botox will exert its actions gradually over the next three 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 any laxative that the doctor prescribe and include fiber in their diet.

After three months, the surgeon will call the patient to discuss about their progress and schedule a follow up meeting. Patients should make sure that they give the correct contact number, otherwise the doctor may not be able to reach them.

What are the risks and side effects of Botox for anal fissures?

As with all surgical procedures, Botox for anal fissures has a risk of causing infection. Most commonly, patients will experience injection-related side effects, such as swelling and pain. Patients should be told of all the potential side effects related to Botox before undergoing the treatment. They should ask the surgeon if they have any questions about the adverse effects of Botox for anal fissures.