What Is the Treatment of Anal Fissure When Topical Therapy Has Not Achieved Healing?

Some anal fissures do not heal following topical medical treatment, including when side effects limited compliance or required switching between agents. In these cases, a defined next-line intervention is indicated.

Previous Line & Failure Condition

The prior step involved a further course of topical treatment — for instance, switching to an alternative agent (such as diltiazem 2% or GTN 0.4%) where side effects such as headache arose. Escalation to this protocol is indicated when healing of the anal fissure was not achieved with that approach.

Next-Line Approach (Overview)

This protocol involves a single procedural injection that can be performed in an outpatient setting or under anaesthesia — with the goal of fissure healing. The complete protocol, including full procedural details, is available below.

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References

DOI: 10.1111/codi.167

For the treatment of anal fissure using botulinum toxin the lowest dose (20–50 U Botox or 50–100 U Dysport) may be considered.

As the optimum site and number of injections is unknown a single injection may be considered.

A two in three healing rate may be expected and there seems to be a negligible risk of long-term continence impairment, though patients should still be warned of the risk of transient flatus incontinence.

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