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Objective: The concept of high muscle tone and spasm contributing to the pain experienced in both anal fissures and levator ani syndrome (LAS) has been well described. A chemical sphincterotomy with botulinum toxin (BT) is one option in patients with anal fissures who fail initial dietary and local measures. Limited data also suggests that BT may be helpful in LAS. The aim of this study was to evaluate the efficacy of BT in the management of anal fissures and LAS. Design: Retrospective cohort study.
Setting: Academic medical center.
Patients: All patients treated with BT for either anal fissure or LAS from 2013 to present.
Results: 29 patients with fissures and 11 with LAS were identified. Nine patients were lost to follow-up. Of 23 patients with anal fissure available for follow-up (mean age 46, 56.5% male), healing occurred in 47.8% after BT treatment, average healing time 2.9m. Lower BT doses were as effective as higher doses. In seven patients with recurrent fissures, following previous lateral internal sphincterotomy, healing rates were considerably higher compared to de novo patients undergoing BT as primary treatment, 71.4% vs. 37.5% respectively (p=0.13). Morbidity was limited, with two patients having mild bleeding and two patients developing transient incontinence that subsequently resolved. Of 8 patients with LAS available for follow-up (mean age 55, 75.0% male) only one reported pain resolution. One LAS patient had limited incontinence after the procedure.
Conclusions: BT is associated with modest healing of anal fissures overall, while chemical denervation for LAS was disappointingly ineffective. The results of BT for recurrent fissures were much more encouraging. In light of its lower morbidity, we suggest BT is preferable to repeat lateral internal sphincterotomy for recurrent anal fissures.