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Technical Note
Anorectal benign disease
 Botulinum injection technique to reduce spasms in refractory anal fissures and after anal fistula or hemorrhoid surgery
Pankaj Garg1orcid, Vipul D. Yagnik2orcid, Kaushik Bhattacharya3orcid
Annals of Coloproctology 2024;40(6):610-612.
DOI: https://doi.org/10.3393/ac.2023.00696.0099
Published online: December 2, 2024

1Garg Fistula Research Institute, Panchkula, India

2Department of Surgery, Banas Medical College and Research Institute, Palanpur, India

3Department of Surgery, MGM Medical College and LSK Hospital, Kishanganj, India

Correspondence to: Pankaj Garg, MS, FASCRS Garg Fistula Research Institute, 1042, Sector-15, Panchkula 134113, India Email: drgargpankaj@yahoo.com
• Received: October 13, 2023   • Revised: December 16, 2023   • Accepted: January 2, 2024

© 2024 The Korean Society of Coloproctology

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Injection of botulinum toxin into the perianal region is employed to alleviate anal spasms resulting from the sustained contraction of the internal anal sphincter, most commonly in cases of acute refractory anal fissure [1, 2]. The spasm is caused by an anal reflex, which is stimulated by perianal pain [3, 4]. Beyond the treatment of acute anal fissures, we also applied botulinum toxin injection during anal fistula and hemorrhoid surgery to reduce postoperative pain and spasm.
After exploring various techniques, we identified an effective method for perianal botulinum injection (Supplementary Video 1):
1. Administering 30 units of botulinum (Boto Genie, BiO-MeD Private Ltd) was sufficient to attain the desired result.
2. Injecting 7.5 units into each of the 4 quadrants (specifically, at the 2, 5, 8, and 11 o'clock positions) proved more effective than the commonly recommended practice of distributing the dosage across only 2 sites.
3. The 30 units may be mixed with saline to achieve a total volume of 5 mL. Subsequently, 1.25 mL of this solution can be administered via injection into the intersphincteric plane within each of the 4 quadrants (Fig. 1).
4. Gentle digital massage of the anal canal, performed for 1 minute with a finger inserted into the anus, was shown to greatly expedite the onset of therapeutic effects. This onset was evident within 24 to 36 hours. Without massage, effects were observed within 48 to 72 hours.
Ethics statement
The study was approved by the Ethics Committee of Indus Hospital (No. EC/02-12). Informed consent for publication of the research details and clinical images was obtained from all participating patients.
Botulinum toxin injection serves as a second-line treatment in the conservative management of refractory anal fissures when traditional medical approaches are unsuccessful [5]. Since lateral internal sphincterotomy (LIS) is a straightforward and popular procedure, many surgeons opt for LIS to treat refractory anal fissures, potentially leading to the underuse of botulinum toxin [5]. However, the principal advantage of botulinum toxin injection is that the resulting decrease in anal sphincter tone is reversible, which is not the case with LIS [6]. Therefore, botulinum toxin injection should be preferred over LIS. A large meta-analysis also highlighted significant continence disturbance after at least 2 years following LIS. Overall rates of disturbance were as high as 14% to 15%, and the most common of these complications was flatus incontinence [6].
Over the past 3 years, we have employed botulinum toxin injections in a total of 455 patients, including outpatient administration for those with refractory anal fissures (n=15) along with intraoperative injections for patients with anal fistulas (n=429) or hemorrhoids (n=11). Of the treated patients, 447 of 455 experienced relief from anal spasms, with the full effect of the botulinum toxin injection manifesting between 24 and 72 hours after the injection. The alleviation of anal spasms was assessed based on the resistance encountered during gentle finger insertion and the level of patient-reported pain during a digital rectal examination (conducted without topical anesthesia) in the outpatient setting. The effect was considered complete when the anal spasm was absent, and finger insertion was smooth and painless during rectal examination. The duration of effect of the botulinum toxin possibly exceeded 8 weeks. However, determining the precise duration was challenging because once the primary pathology resolved, the cause of the anal spasm was no longer present. Consequently, it became unclear whether the absence of anal spasms was due to the resolution of the pathology or the ongoing impact of the botulinum toxin. The sole complication observed following botulinum toxin injection was temporary flatus or urge incontinence, which occurred in the first 4 weeks after receiving the injection in 21 patients (4.6%). However, this issue was resolved in all affected patients through Kegel (pelvic floor) exercises and also improved as the effects of the injection diminished over time.
As no standardized process has been established for botulinum toxin injection, we have endeavored to refine the procedure over the past 3 years. We observed that administering the injection into each of the 4 quadrants was more effective than administering it in only 2 sites. Additionally, we found that a straightforward technique involving a gentle 1-minute massage of the anal canal with a finger inserted into the anus markedly enhanced the early onset of the injection’s effects. The importance of this early onset cannot be overstated, as patients experience considerable pain and anticipate prompt symptom relief, particularly following the injection. These clear, straightforward measures were instrumental in providing patients with complete and rapid relief, greatly increasing their satisfaction. These findings have been supported by several surgeons who have adopted this botulinum toxin injection technique.
In conclusion, the method of administering botulinum toxin injections into 4 quadrants rather than 2 sites, coupled with gentle massage of the anal canal following injection, was straightforward, easily implemented, and highly effective.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Acknowledgments

The authors thank Khushhreet Garg for his assistance in producing and editing the videos.

Author contributions

Conceptualization: PG, VDY, KB; Investigation: PG, VDY; Methodology: PG, KB; Validation: PG, VDY, KB; Visualization: PG, VDY; Writing–original draft: PG; Writing–review & editing: PG, VDY, KB. All authors read and approved the final manuscript.

Supplementary Video 1.
Technique for botulinum injection into the perianal region.
Supplementary materials are available from https://doi.org/10.3393/ac.2023.00696.0099.
Fig. 1.
Schematic diagram illustrating the injection of botulinum toxin into the intersphincteric plane.
ac-2023-00696-0099f1.jpg
  • 1. Aivaz O, Rayhanabad J, Nguyen V, Haigh PI, Abbas M. Botulinum toxin A with fissurectomy is a viable alternative to lateral internal sphincterotomy for chronic anal fissure. Am Surg 2009;75:925–8.ArticlePubMedPDF
  • 2. Brisinda G, Cadeddu F, Brandara F, Marniga G, Vanella S, Nigro C, et al. Botulinum toxin for recurrent anal fissure following lateral internal sphincterotomy. Br J Surg 2008;95:774–8.ArticlePubMedPDF
  • 3. Berkel AE, Rosman C, Koop R, van Duijvendijk P, van der Palen J, Klaase JM. Isosorbide dinitrate ointment vs botulinum toxin A (Dysport) as the primary treatment for chronic anal fissure: a randomized multicentre study. Colorectal Dis 2014;16:O360–6.ArticlePubMed
  • 4. Witte ME, Klaase JM, Koop R. Fissurectomy combined with botulinum toxin A injection for medically resistant chronic anal fissures. Colorectal Dis 2010;12(7Online):e163–9.Article
  • 5. Mishra S, Thakur DS, Somashekar U, Verma A, Sharma D. The management of complex fistula in ano by transanal opening of the intersphincteric space (TROPIS): short-term results. Ann Coloproctol 2024;40:474–80.Article
  • 6. Garg P, Garg M, Menon GR. Long-term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis. Colorectal Dis 2013;15:e104–17.ArticlePubMed

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        Botulinum injection technique to reduce spasms in refractory anal fissures and after anal fistula or hemorrhoid surgery
        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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      Botulinum injection technique to reduce spasms in refractory anal fissures and after anal fistula or hemorrhoid surgery
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      Fig. 1. Schematic diagram illustrating the injection of botulinum toxin into the intersphincteric plane.

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      Botulinum injection technique to reduce spasms in refractory anal fissures and after anal fistula or hemorrhoid surgery
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