This protocol addresses the clinical situation of a female patient with a chronic anal fissure that has persisted despite laxatives, topical therapy, and a subsequent course of botulinum toxin injection — where healing of the fissure was not achieved.

Clinical scenario

Female sex is a specific and important factor in the management of chronic anal fissure. The anatomical differences in sphincter structure in female patients directly shape the choice and extent of any surgical intervention considered at this stage.

Previous treatment — goal not reached

The preceding treatment line — botulinum toxin injection — did not achieve the target goal of healing of the fissure. This protocol is the structured next step taken after that failure.

Treatment approach (partial — full regimen requires access)

At this stage, a surgical approach is indicated. The specific technique is chosen with particular care in female patients, with tailoring based on individual clinical factors — including any concerns about continence. The treatment goal remains healing of the fissure.

References DOI: 10.1111/codi.167

For female patients with chronic fissure persisting after laxatives and topical therapy, botulinum toxin may be considered.

Female patients with chronic fissure persisting after laxatives and topical therapy may be considered for lateral internal sphincterotomy with caution.

In female patients having internal sphincterotomy, minimal incision of the muscle may be considered.

Alternative sphincter preserving surgery may be considered, especially in patients with continence impairment.

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Chronic Anal Fissure in Female Patients: Next Step After Botulinum Toxin Has Not Achieved Healing