BOTOX for resistant chronic anal fissure. Guy Nash
Chronic Fissure
During the past few years there has been renewed interest in the medical
management of chronic anal fissure. For those patients who have failed
topical GTN and Diltiazem, surgery usually is the next treatment offered.
A group of patients who have had previous insults to anal continence,
including difficult obstetric deliveries or anal surgery, are most at risk of
frank incontinence following fissure surgery. Botox (botulinum
neurotoxin) has been recently established as a second or third line
treatment, following failed topical treatments in those at highest risk of
incontinence. In addition, occasionally patients unable to comply with
topical treatment or those unsuitable for a general anaesthetic would be
candidates for botox as first line treatment.
Treatment with botulinum neurotoxin is less expensive and easier to
perform than surgery and does not require anesthesia. It is also safe (1)
and more efficacious (2) than nitrate therapy and is not related to the
patient compliance.
Method: The use of botox (8- 10 units to either side of the anus between
the internal and external sphincters) for these patients would reduce the
chance of permanent incontinence. This would add a therapeutic option in
these patients who are difficult to treat and hopefully reduce the chance of
patients becoming incontinent. Each patient should be consented for
temporary incontinence is a recognised adverse effect of botox treatment,
and using larger doses of Botox has been reported at least once to cause a
permanent incontinence.
My experience of administering botox for chronic anal fissure is that it is
well tolerated in an outpatient setting and I have had no side effects
reported in those patients I have treated at St. Marks & Poole Hospitals.
The indication should not normally include first line treatment in my
opinion as there are other even cheaper and safer treatment that are well
tolerated (topical agents such as diltiazem 2% which avoids the headache
associated with GTN cream).For suitable patients, consented and
personally consulted, I believe botox would be a valuable treatment for a
persistent and often miserable condition.
References
1. Madalinski M, Slawek J, Duzynski W, Zbytek B, Jagiello K Adrich Z,
et al. Side effects of botulinum toxin injection for benign anal disorders.
Eur J Gastroenterol Hepatol 2002; 14: 853-6.
2. Jost WH, Schimrigk K. Use of botulinum toxin in anal fissure. Dis
Colon Rectum 1993; 36: 974.