Annals of Coloproctology

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Original Article

Anorectal benign disease

Long-term outcomes of intramural rectal botulinum toxin injections for urge fecal incontinence: a salvage therapy for sacral neuromodulation nonresponders?: Philippe Onana Ndong, Véronique Vitton; Ann Coloproctol. 2025;41(5):417-423. Published online October 23, 2025; DOI: https://doi.org/10.3393/ac.2025.00332.0047

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Graphical Abstract Abstract PDF: Purpose
Sacral neuromodulation (SNM) failure in fecal incontinence (FI) management represents a therapeutic challenge, often leading to more invasive, less accepted alternatives with inconsistent efficacy. In this context, intramural rectal botulinum toxin A (BoNT-A) injection has recently emerged as a promising minimally invasive alternative for urge FI. This study aimed to evaluate the effectiveness of intramural rectal BoNT-A injections in the challenging subgroup of SNM nonresponders.
Methods
This retrospective, single-center study included patients with urge FI who underwent intramural rectal BoNT-A injections after SNM failure, between February 2018 and September 2024. The procedure involved endoscopic injection of 200 units of BoNT-A at 10 circumferential sites in the rectal wall. Treatment efficacy was assessed using the Cleveland Clinic Fecal Incontinence Score (CCFIS) and a visual analog scale (VAS) for symptom severity.
Results
Fifteen female patients met the inclusion criteria, with a median follow-up of 22.5 months (range, 4.4–103.2 months). Patients received a median of 2 injections, with a median reinjection interval of 9.8 months. CCFIS scores demonstrated significant improvement (median, 15 [range, 8–20] vs. 8 [range, 0–20]; P=0.001), as did VAS symptom scores (median, 4 [range, 0–5] vs. 2 [range, 0–5]; P=0.001). No adverse events were reported.
Conclusion
This study provides long-term evidence supporting intramural rectal BoNT-A injections as an effective option for managing urge FI, including as salvage therapy in SNM nonresponders. Further studies are necessary to confirm these findings and define the optimal role of BoNT-A within the therapeutic algorithm for urge FI.

Technical Note

Anorectal benign disease

Botulinum injection technique to reduce spasms in refractory anal fissures and after anal fistula or hemorrhoid surgery: Pankaj Garg, Vipul D. Yagnik, Kaushik Bhattacharya; Ann Coloproctol. 2024;40(6):610-612. Published online December 2, 2024; DOI: https://doi.org/10.3393/ac.2023.00696.0099

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Original Article

Clinical trial of combining botulinum toxin injection and fissurectomy for chronic anal fissure: a dose-dependent study: Nuha Alsaleh, Abdullah I. Aljunaydil, Gaida A. Aljamili; Received March 24, 2021 Accepted July 27, 2021 Published online December 3, 2021; DOI: https://doi.org/10.3393/ac.2021.00213.0030 [Epub ahead of print]

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2 Citations

Abstract PDF

Purpose
Our aim was to evaluate the effectiveness of combining fissurectomy with botulinum toxin A injection in treating chronic anal fissures.
Methods
A single surgeon in Saudi Arabia conducted a nonrandomized prospective cohort study between October 2015 and July 2020. The cohort included 116 female patients with chronic anal fissures, with a mean age of 36.57±11.52 years, who presented to the surgical outpatient clinic and received a botulinum toxin injection combined with fissurectomy. They were followed up with at 1, 2, 3, 4, and 8 weeks to evaluate the effects of the treatment, then again at 1 year. The primary outcome measures were symptomatic relief, complications, recurrence, and the need for further surgical intervention.
Results
Treatment with botulinum toxin A combined with fissurectomy was effective in 99.1% of patients with chronic anal fissures at 1 year. Five patients experienced recurrence at 8 weeks, which resolved completely with a pharmacological sphincterotomy. Twelve patients experienced minor incontinence, which later disappeared. Pain completely disappeared in more than half of the patients (55.2%) within 7 to 14 days. Pain started to improve in less than 8 days among patients treated with a dose of 50±10 IU (P=0.002).
Conclusion
Seventy units of botulinum toxin A injection combined with a fissurectomy is a suitable second-line treatment of choice for chronic anal fissures, with a high degree of success and low rate of major morbidity.

Citations

Citations to this article as recorded by

Fissurectomy with mucosal advancement flap anoplasty: The end of a dogma?
M. Skoufou, J.H. Lefèvre, A. Fels, N. Fathallah, P. Benfredj, V. de Parades
Journal of Visceral Surgery.2023; 160(5): 330. CrossRef
La fissurectomie avec anoplastie muqueuse : la fin d’un dogme ?
Maria Skoufou, Jérémie H. Lefèvre, Audrey Fels, Nadia Fathallah, Paul Benfredj, Vincent de Parades
Journal de Chirurgie Viscérale.2023; 160(5): 363. CrossRef

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