Bilateral versus unilateral botulinum toxin injections for chronic anal fissure: a randomised trial

Abstract

BackgroundBotulinum toxin injected into the internal anal sphincter is used in the treatment of chronic anal fissure but there is no standardised technique for its administration. This randomised single centre trial compares bilateral (either side of fissure) to unilateral injection.MethodsParticipants were randomised to receive bilateral (50 + 50 units) or unilateral (100 units) Dysport® injections into the internal anal sphincter in an outpatient setting. Injection-related pain assessed by visual analogue scale was the primary outcome measure. Secondary outcomes were healing rate, fissure pain, incontinence, and global health scores.ResultsBetween October 2008 and April 2012, 100 patients with chronic anal fissure were randomised to receive bilateral or unilateral injections. Injection-related pain was comparable in both groups. There was no difference in healing rate. Initially, there was greater improvement in fissure pain in the bilateral group but at 1 year the unilateral group showed greater improvement. Cleveland Clinic Incontinence score was lower in the unilateral group in the early post-treatment period and global health assessment (EuroQol EQ-VAS) was higher in the unilateral group at 1 year.ConclusionsInjection-related pain was similar in bilateral and unilateral injection groups. Unilateral injection was as effective as bilateral injections in healing and improving fissure pain without any deterioration in continence.Electronic supplementary materialThe online version of this article (10.1007/s10151-018-1821-2) contains supplementary material, which is available to authorized users.

A New Botox Therapy Method in Chronic Anal Fissüre

“…They performed 50 IU unilaterally in the rst group and 50 IU bilaterally in the second group. According to the results of this study, they reported that unilateral 50 IU BT was su cient to prevent recurrence and e cacy [20].…”

Safety and efficacy of the treatment of chronic anal fissure by lateral internal sphincterotomy: A retrospective cohort study

“…An earlier study observed that dietary bran supplements and warm sitz baths effectively treat acute anal fissures [ 22 ]. The other medical management process is termed as “chemical sphincterotomy”, where pharmacological agents such as glyceryl trinitrate or calcium blockers, and botulinum toxin (BT) injection are applied to treat chronic anal fissures [ [8] , [9] , [10] , [11] ]. However, it is not considered an effective treatment strategy and has a low success rate [ 6 , 23 ].…”

“…Similarly, The American Society of Colon and Rectal Surgeons (ASCRS) guidelines recommend that for the initial nonsurgical management of anal fissure, the patient should be recommended stool softeners, high fiber diet, and warm sitz bath [ 7 ]. Application of pharmacological agents such as glyceryl trinitrate or calcium blockers, and botulinum toxin (BT) injection are other treatment strategies, which are also termed as “chemical sphincterotomy” [ [8] , [9] , [10] , [11] ]. However, the success rate (65–75%) of this treatment strategy is significantly lower than as observed in surgical sphincterotomy [ [11] , [12] , [13] ].…”

Anorectal emergencies: WSES-AAST guidelines

“…The authors concluded that the use of a single posterior injection is more tolerable and less painful than bilateral injection [317]. Few other studies analyzed the role of Botulinum toxin for the treatment of chronic AF [318,319]. The results of these studies regarding the dose, preparation, and the site of injection are interesting but cannot be extended to the treatment of acute anal fissures.…”