Treatment with Botulinum Toxin in Children with Chronic Anal Fissure

Abstract

Introduction: Chronic anal fissures with painful defecation and bloodstained stools can be seen in children of all ages. Constipation may precede or appear in connection with the symptoms. Adult patients with anal fissures have been treated successfully with the injection of botulinum toxin into both the internal and external sphincter. The effect of botulinum toxin is reversible and lasts for 3–4 months. This pilot study attempted to examine whether botulinum toxin is also effective in paediatric cases of anal fissure, a treatment which not yet has been reported in the literature.

Material and methods: Six boys and seven girls aged 1–10 years were treated with botulinum toxin (Botox^®) during 2002–2005 due to chronic anal fissure. Conventional treatment with laxatives and local anaesthetics had been unsuccessful in all cases. The treatment was given to five children under 2 years of age in a dosage of 1.25 U×2. Eight children over 2 years of age were given 2.5 U×2. The injections were given in the external sphincter on both sides of the fissure using EMG-stimulation for guidance and were performed under light anaesthetics (Diprivan^®). Follow-up was conducted at 1 and 3 months after treatment.

Results: Within one week, 11 of the children were free from pain and blood stained stools, according to their parent's observations. One 10-year old patient initially showed some improvement but soon experienced a recurrence. After another injection with a higher dosage 2 months later, the fissure healed. One 4-year old patient did not show any signs of improvement. The laxatives, which had been withdrawn after the injection treatment, were then reinstated. At the 3 month post-treatment examination the patient was finally symptom-free with no signs of a fissure. There were no negative side-effects detected in any of the cases. Seven recurrences were noted in 6 of the patients after 3–30 months, often in connection with an episode of constipation. Repeat injections were offered and accepted by four of these patients, once more producing good immediate results.

Conclusion: Treatment with botulinum toxin in the external sphincter produces a quick and effective alleviation of pain with healing of chronic anal fissures in children. The treatment is not considered to carry any risks but requires light anaesthesia. Recurrences are common after the pharmacological effect has receded but can be cured with an additional injection.

Key words

anal fissure - botolinum toxin - chronic constipation

References

• 1 Amendola S, De Angelis P, Dall’Oglio L. et al . Combined approach to functional constipation in children.  J Pediat Surg. 2003;  38 819-823
• 2 Brisinda G, Bentivoglio AR, Maria G. et al . Treatment with botulinum toxin of gastrointestinal smooth muscles and sphincter spasms.  Mov Disord. 2004;  19 146-156
• 3 Fernández Lopes F, Conde Freire R, Rios Rios A. et al . Botulinum toxin for the treatment of anal fissure.  Dig Surg. 1999;  16 515-518
• 4 Gui D, Rossi S, Runfola M. et al . Review article: botulinum toxin in the therapy of gastrointestinal motility disorders.  Aliment Pharmacol Ther. 2003;  18 1-16
• 5 Jones OM, Moore JA, Brading AF. et al . Mechanism of action of botulinum toxin on the internal anal sphincter.  Br J Surg. 2004;  91 224-228
• 6 Jost WH, Schimrigk K. Use of botulinum toxin in anal fissure.  Dis Colon Rectum. 1993;  36 974
• 7 Jost WH, Schimrigk K. Botulinum toxin in therapy of anal fissure.  Lancet. 1995;  345 188-189
• 8 Jost WH, Schrank B. Repeat botulinum toxin injections in anal fissure in patients with relapse and after insufficient effect of first treatment.  Dig Dis Sci. 1999;  44 1588-1589
• 9 Keshtgar AS, Ward HC, Clayden GS. et al . Role of anal dilatation in treatment of idiopathic constipation in children: long-term follow-up of a double-blind randomized controlled study.  Pediatr Surg Int. 2005;  21 100-105
• 10 Lund JN, Scholefield JH. Aetiology and treatment of anal fissure.  Br J Surg. 1996;  83 1335-1344
• 11 Mense S. Neurobiological basis for the use of botulinum toxin in pain therapy.  J Neurol. 2004;  251 ((suppl 1)) 11-17
• 12 Maria G, Cassetta E, Gui D. et al . A comparison of botulinum toxin and saline for the treatment of chronic anal fissure.  New Eng J Med. 1998;  338 217-220
• 13 Mason PF, Watkins MJ, Hall HS. et al . The management of chronic fissure in-ano with botulinum toxin.  J R Coll Surg Edinb. 1996;  40 235-238
• 14 Nelson R. A systematic review of medical therapy for anal fissure.  Dis Colon Rectum. 2004;  47 422-431
• 15 Nielsen MB, Rasmussen OO, Pedersen JF. et al . Risk of sphincter damage and anal incontinence after anal dilatation for fissure-in-ano: an endosonographic study.  Dis Colon Rectum. 1993;  37 677-680
• 16 Pamphlett R. Early terminal and nodal sprouting of motor axons after botulinum toxin.  J Neurol Sci. 1989;  92 181-192
• 17 Sönmez K, Demirogullari B, Ekingen G. et al . Randomized, placebo-controlled treatment of anal fissure by lidocaine, EMLA, and GTN in children.  J Pediatr Surg. 2002;  37 1313-1316
• 18 Tander B, Glven A, Demirbag Y. et al . A prospective, randomized, double-blind, placebo-controlled trial of glyceryl-trinitrate ointment in the treatment of children with anal fissure.  J Pediatr Surg. 1999;  34 1810-1812
• 19 Utzig MJ, Kroesen AJ, Buhr HJ. Concepts in pathogenesis and treatment of chronic anal fissure – a review of the literature.  Am J Gastroenterol. 2003;  98 968-974

Correspondence