Injection of Botox and sphincterotomy

Anal fissures can be excruciatingly painful and the first way to treat them is with topical creams which should be used regularly for six weeks. Rectogesic (Glyceryl Trinitrate) and Anoheal (Diltiazem) are similar in their efficacy and should be applied at least a couple of time a day for six weeks. They will heal about 60-70% of fissures. If they fail to work, your surgeon may suggest an alternative treatment.

Botox injection has gained popularity for treating this group of patients. Botox is injected close to or into the internal sphincter muscle. The injection works by causing the muscle to become paralysed and thereby reducing the amount of spasm or contraction that it undergoes in conjunction with a fissure. This enforces relaxation and allows more blood to the area to heal the fissure. The Botox lasts in your system for between 8-12 weeks. This will usually allow the fissure enough time to heal. It is usually well tolerated but does require a general anaesthetic to administer. This will also allow the surgeon to examine you in some detail, which may be too uncomfortable in the clinic. As it is well tolerated, people who fail to heal on the first injection may often be offered repeated injections in an attempt to heal the fissure. If the fissure still continues to be a problem despite repeated Botox injections, then two further procedures may be considered depending on your case. Due to the weakening of the muscle, some people do experience a degree of urgency after the injection, although this is temporary as the Botox does wear off.

A special type of procedure called an advancement flap can sometimes be used to excise the fissure and to advance a healthy bit of tissue over the excision site which is then sutured into place. The other alternative is a lateral sphincterotomy.  This is where a targeted cut is made in the muscle; usually done under ultrasound guidance. The length of muscle being cut usually correlates to the length of the fissure and great care is taken not to cut too much of the muscle as this can render it permanently weak and lead to weakness, urgency and sometimes incontinence. It is because of this side effect that it is used as a last resort, although it usually does have very good rates of healing fissures.

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