Toxin Botulinum In The Treatment Of Anal Pain Due To Anal Fissure: Is The Definitive Solution?

Background and aims: Anal pain due to fissure is a common and painful proctologic disorder in healthy population. The pathogenesis is understood but persistent hypertonia of the internal anal sphincter seems to play an important role. The aim of this prospective trial was to evaluate the effectiveness and morbidity of chemical sphincterotomy with botulinum toxin that produce relaxation of anal sphincter and disappearance of pain. Methods: We treated 200 consecutive patients with chronic anal pain with 25U botulinum toxin injected into the internal sphincter. Clinical results were recorded at the time of admission and at one-week, two-month, six-month and anually visits. Results: No major complications were found; initial incontinence (5%) spontaneously reversed at the six-month. There was a tendency of progressive recurrence over time, with an overall recurrence in the exploration after one year of 52%. However, 80% of the global serie heal or dissapear or improve previous pain; and did not complementary medical or surgical treatment.We found a group of patients with clinical factors (length of the disease longer than 12 months and presence of a sentinel pile) associated with a higher recurrence. Conclusions: We recommend the use of botulinum toxin for the treatment of anal pain due to anal fissure because improve anal pain in 80% of patients. In patients with symptomatic recurrence associated to risk clinical parameters surgical treatment should be considered in the view of the high probability of recurrence in the long-term follow-up.