Botulinum Toxin Injections for Anal Fissures

Anal fissures can cause agonising discomfort, and using the loo can become unpleasant and feared. People may avoid treatment for anal fissures owing to embarrassment or ignorance about available treatment alternatives.

If an anal fissure does not heal with conservative means, Botulinum Toxin injection into the internal anal sphincter may be used, and no, this is not to attain a wrinkle-free anus!

An anal fissure, once established, causes spasms of the internal anal sphincter. Botulinum Toxin is intended to relax this spasm sufficiently to alleviate pain and suffering while healing the fissure. Botulinum Toxin injections are not unpleasant; however, they are generally given under anaesthesia to allow for a complete evaluation and, if necessary, remove any related tags.

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What are Botulinum Toxin Injections?

Botulinum toxin, better known by its brand name Botox, is a neurotoxin that interrupts nerve signals to prevent muscle contractions. While it is most famously used for cosmetic purposes, it also has therapeutic benefits for various medical conditions, such as anal fissures.

When administered into the internal anal sphincter, Botulinum toxin works by relaxing the muscle, thereby reducing pressure at the site of the fissure and allowing it to heal.

Botulinum Toxin Can Treat Anal Fissures?

Botulinum Toxin Type A blocks muscle contractions and is commonly used for conditions involving muscle spasms. While it is widely known for its use in cosmetic facial injections, studies support its use for treating chronic anal fissures. The American Society of Colon and Rectal Surgeons recommends Botulinum Toxin Type A as an effective treatment option for this condition.

How Effective is Botulinum Toxin for Anal Fissures?

Botulinum Toxin Type A injections offer an alternative for managing anal fissures, especially for patients who prefer to avoid surgery or are beginning treatment. The success rate is approximately 60%, and the procedure is performed under sedation combined with a local perianal anesthetic. This approach minimises risks such as infection and bleeding associated with surgical procedures and allows the patient to avoid hospitalisation.

However, a temporary side effect may occur: a slight decrease (about 5%) in anal muscle control, which typically resolves within three months as the medication wears off.

Why Do You Need Botulinum Toxin for Chronic Anal Fissures?

The Benefits of Botulin Toxin A are that the paralysing effect lasts just 2-3 months, with complete recovery of muscular function thereafter. In most circumstances, this is plenty of time to allow the anal fissure to heal. Long-term permanent incontinence has not been documented after 1-2 doses. This is in contrast to surgery (e.g., lateral internal spincterotomy), where the rates of persistent mild incontinence can reach 20% and total incontinence up to 5%.2 Combining Botulin with topical gels, such as previously described, is more likely to be effective than alone.

Benefits of Botulinum Toxin for Chronic Anal Fissures

• No surgical scars
• Lower risk of infection
• Fewer complications compared to surgery, such as post-operative bleeding
• Eliminates the need for hospitalization

Botulinum Toxin injections for treating anal fissures

Botulinum toxin injection is a viable alternative to surgery for the treatment of simple idiopathic anal fissure. Patients who do not respond to Botulinum toxin injections or have a severe anal fissure should be given surgery.

What is Anal Fissure?

Anal Fissure is a tear at the anus's edge, which is commonly caused by passing hard or big faeces. Patients generally report cutting pain in the behind during defecation, perhaps with fresh red blood on the stool or toilet paper. Diagnosis is done by medical history and physical examination, revealing a tear at the edge of the anus.

What Are the Causes of Anal Fissures?

Anal fissures are small tears or cracks in the lining of the anus. They can be quite painful and are usually caused by trauma or injury to the anal canal. Here are some common causes of anal fissures.

Common causes of anal fissures are:

• Passing huge, hard stools.
• Constipation and strain during bowel motions.
• Long-term diarrhoea.
• Anal intercourse.
• Childbirth.

Less prevalent causes of anal fissures are:

• Crohn's disease or another inflammatory bowel condition.
• Anal cancer.
• HIV
• Tuberculosis.
• Syphilis
  
  

Symptoms of an Anal Fissure

Common signs of an anal fissure may include:

• Pain while passing stool.
• Persistent pain after bowel movements that can last for hours.
• Bright red blood on the stool or visible on toilet paper following a bowel movement.
• A noticeable tear or crack in the skin surrounding the anus.
• A small bump or skin tag near the site of the fissure.

Types of Anal Fissures

There are two types of anal fissures, classified by duration:

1. Acute Anal Fissure: Symptoms last from days to weeks and often heal with treatment, such as laxatives for constipation, fibre supplements to soften stools, and pain relief medications (topical or oral).
2. Chronic Anal Fissure: This develops when healing is slow, often accompanied by anal sphincter spasms, reducing blood flow to the midline of the anus and delaying recovery. Symptoms persist for over six weeks, causing consistent pain during bowel movements, even with soft stools. Chronic fissures may show deep tears, skin tags (sentinel piles), or internal growths resembling haemorrhoids (hypertrophic anal papilla). Surgery is usually required for treatment.