Botox and CCBs were equivalent to GTN in efficacy with fewer adverse events .
No medical therapy came close to the efficacy of surgical sphincterotomy , though none in these RCTs was associated with the risk of incontinence .
Medical therapy for chronic anal fissure , acute fissure and fissure in children may be applied with a chance of cure that is marginally better than placebo , and , for chronic fissure in adults , far less effective than surgery
BACKGROUND Because of the disability associated with surgery for anal fissure and the risk of incontinence , medical alternatives for surgery have been sought .
Most recently , pharmacologic methods that relax the anal smooth muscle , to accomplish reversibly what occurs in surgery , have been used to obtain fissure healing .
OBJECTIVES To assess the efficacy and morbidity of various medical therapies for anal fissure .
Comparison of Botulinum Toxin Injection and Lateral Internal Sphincterotomy for the Treatment of Chronic Anal Fissure
Abstract PURPOSE : Botulinum toxin injection into the internal anal sphincter has been shown to be an effective treatment for chronic anal fissure . A r and omized , prospect i ve trial was conducted to compare botulinum toxin with lateral internal anal sphincterotomy as definitive management for chronic anal fissure . METHODS : Patients diagnosed as having chronic anal fissure were r and omly assigned to one of the two treatment arms . In the botulinum toxin  group ( n = 61 ) , 20 to 30 U ( approximately 0.3 U/kg ) of type A botulinum toxin ( Botox ® ) was injected into the internal anal sphincter . The injection was repeated two months later if complete healing was not accomplished . Patients in the sphincterotomy group ( n = 50 ) underwent lateral internal anal sphincterotomy . The same investigators evaluated the patients on postoperative/postinjection days 7 and 28 , and then in a blinded manner at 2 , 6 , and 12 months . RESULTS : In the botulinum group , single injection result ed in complete healing in 45 of the 61 patients ( 73.8 percent ) at the second month . Of the 16 failures , 6 patients refused further treatment , and 10 were treated with a second injection , which result ed in an overall healing rate of 86.9 percent ( 53/61 ) at 6 months . In the sphincterotomy group , the success rate was 82 percent ( 41/50 ) at day 28 and 98 percent ( 49/50 ) at the second month ( P = 0.023 and P < 0.0001 , respectively , compared with the botulinum group — single injection ) . At 6 months , 2 patients in the LIS group developed recurrences , and the healing rate was similar to that of the botulinum group ( 86.9 vs. 96.4 percent ; P = 0.212 ) . At 12 months , the success rate of the Botox ® group fell to 75.4 percent ( 46/61 ) with 7 recurrences , whereas it remained stable in the sphincterotomy group ( 94 percent , P = 0.008 ) . Sphincterotomy was associated with a significantly higher complication rate ( 8 cases of anal incontinence vs. none in the botulinum toxin group ; P < 0.001 ) . Full return to daily activities took significantly less time in the botulinum group ( 1 vs. 14.8 ± 5.7 days ; P < 0.0001 ) . CONCLUSION : Although the healing rate of chronic anal fissure is considerably high with botulinum toxin injection with earlier recovery and less complications compared with sphincterotomy , it occasionally requires a repeat injection , and the healing is slower . The early ( two months ) and late ( one year ) healing rates are significantly higher in the sphincterotomy group , the two groups reaching similar healing rates only at six months
Botox and CCBs were equivalent to GTN in efficacy with fewer adverse events .
No medical therapy came close to the efficacy of surgical sphincterotomy , though none in these RCTs was associated with the risk of incontinence .
Medical therapy for chronic anal fissure , acute fissure and fissure in children may be applied with a chance of cure that is marginally better than placebo , and , for chronic fissure in adults , far less effective than surgery
BACKGROUND Because of the disability associated with surgery for anal fissure and the risk of incontinence , medical alternatives for surgery have been sought .
Most recently , pharmacologic methods that relax the anal smooth muscle , to accomplish reversibly what occurs in surgery , have been used to obtain fissure healing .
OBJECTIVES To assess the efficacy and morbidity of various medical therapies for anal fissure .