ABSTRACT
BACKGROUND: Botulinum toxin A (BT-A) injection into internal or external anal sphincter causes relaxation of the anal sphincters, enhancing microcirculation at the fissure site and promoting fissure healing. There are no such observations in patients with secondary anal fissure. METHODS: Six patients with fissures after surgical or nonsurgical treatment of hemorrhoids and four patients with ulcerative colitis received injections of BT-A on both edges of the fissure (total dose, 25 U Botox). RESULTS: In the week following BTA injection, patients with fissure after hemorrhoids treatment had relief of fissure symptoms, but one month later the fissures still existed. They then received an additional 25 U Botox. One month after the second BT-A injection, all fissures were healed. The patients with ulcerative colitis had only symptomatic improvement after BT-A injection. CONCLUSION: BT-A therapy seems effective for the treatment of chronic anal fissure after surgical or nonsurgical treatment of hemorrhoids.
Subject(s)
Botulinum Toxins, Type A/therapeutic use , Fissure in Ano/etiology , Fissure in Ano/therapy , Adult , Chronic Disease , Colitis, Ulcerative/complications , Colitis, Ulcerative/surgery , Female , Fissure in Ano/physiopathology , Follow-Up Studies , Hemorrhoids/complications , Hemorrhoids/surgery , Humans , Injections, Intralesional , Male , Middle Aged , Prospective Studies , Risk Assessment , Sampling Studies , Severity of Illness Index , Treatment Outcome , Wound Healing/physiologySubject(s)
Anti-Dyskinesia Agents/therapeutic use , Botulinum Toxins/therapeutic use , Esophageal Achalasia/drug therapy , Anti-Dyskinesia Agents/administration & dosage , Anti-Dyskinesia Agents/pharmacology , Botulinum Toxins/administration & dosage , Botulinum Toxins/pharmacology , Humans , Nitrates/therapeutic useABSTRACT
BACKGROUND/AIMS: Combined BT-A (botulinum toxin A) therapy and local application of nitrates can be more effective than BT-A alone for chronic anal fissure treatment, but so far the optimal dose of BT-A is not known. The aim of our study was to learn if BT-A doses higher than those used so far could change the outcome of fissure treatment. METHODOLOGY: We enrolled 14 consecutive patients suffering from idiopathic chronic anal fissure who did not respond to previous local treatment of nitric oxide donor and subsequent BT-A therapy (25 U of Botox). They were offered a local nitroglycerin treatment. In failure cases patients received the greater doses of BT-A (50 U of Botox). RESULTS: In all 11 patients with chronic anal fissure who applied nitroglycerin after BT-A injection, an effect on the internal anal sphincter relaxation was observed but fissure healing after topical nitroglycerin occurred only in 1 case. Of 13 patients with chronic anal fissure who received 50 U of BT-A no healing was reported in 6 cases. One male from this group received a greater dose (100 U of Botox) and then the fissure healed. CONCLUSIONS: The effect of topical nitrates on internal anal sphincter relaxation after botulinum toxin injection is not the last line for nonsurgical treatment of chronic anal fissure. Always we ought to consider using the next greater dose of BT-A before surgical treatment.
