1. Introduction

2. Botox Preparation

3. Anal Examination Under Anesthesia

4. Botox Injection

a. Mucosal Approximation

5. Final Inspection of Fissures

6. Post-op Local Anesthetic

7. Post-op Remarks

Most individuals associate anal pain with hemorrhoids. However, there are many conditions that can cause anal pain and bleeding, and physical examination helps to differentiate between these diagnoses: anal fissures, hemorrhoids, or infections. An anal fissure is a superficial tear in the anoderm. Fissures are diagnosed clinically by history and physical exam with careful spreading of the anus and direct visualization of a break in the mucosa and exposed sphincter fibers. Increased tone of the internal anal sphincter can inhibit fissure healing by decreasing blood flow to the mucosa. Conservative management includes stool softeners and warm sitz baths to avoid traumatizing the fissure with hard stools and relaxing the sphincters with warm water. Topical nitrates or calcium channel blockers applied at the anal verge dilate and relax the internal sphincter muscle to promote healing. Alternatively, injection of Onobotulinumtoxin A into the fissure and intersphincteric groove paralyzes sphincter muscle, decreasing muscle spasm and supporting healing of the fissure. For individuals who fail these conservative therapies, lateral internal sphincterotomy is considered. This procedure involves dividing the internal sphincter muscles but carries a small risk of fecal incontinence. We present the case of young adult male with a history of a chronic anal fissure, who failed medical management. Posterior anal fissure was appreciated on exam and treated with Onobotulinumtoxin A injection for relaxation of anal sphincter.

<h4>CHAPTER 1</h4>

<p>Hi, I'm Dr. Brooke Gurland.
I am a colorectal surgeon and I work at
the Stanford Pelvic Health Center.
I do a lot of anorectal work,
and with anorectal, you frequently see anal pain,
chronic anal fissures, hemorrhoids, and whatnot.
And almost everybody comes in saying
that they have a hemorrhoid, but actually
there's many other diagnoses that it could be.
In this specific case, I am taking care of a young gentleman
in his twenties who has had chronic anal fissures
and he's had several different treatments in the past.
For chronic anal fissures, we usually talk about
making sure that the bowels are soft,
doing things like sitz baths, so that relax the muscle
and help the fissure to heal as well as either
a calcium channel blocker to apply to the anal area
or a nitroglycerin; both of those help
relax smooth muscle and allow a fissure to heal.
Now he has done all of those things
and yet he continues to have fissures.
And at some point he did them, and it improved a little bit,
and actually his fissure's been going on for several years.
So he's done that.
He actually has even done some pelvic floor physical therapy
and that is to learn coordination as well as relaxation.
So he is really quite adept at this point
in knowing what his bowel movements are like
and doing a lot of behavioral modification.
So when he came back in to see me after some time
with persistent pain, he actually knew exactly what he had,
which was the fissures, and had already initiated
the creams, which he had done for a certain time period.
And then when I took a look in the office,
I could see that he had anal fissures.
And I like the term chronic anal fissures
in that it has been going on for some time.
As well as I could see the white fibers
of the sphincter muscle - 
it's showing me that there's some chronicity.
So my plan for him - he has two actual or, you know,
three options, in that he could stay as he is.
Another option would be to inject Botox,
and that's injected into the actual fissures into
the internal sphincter to help with relaxation and healing.
And then the kind of gold standard, or the go-to at the end
would be something called internal sphincterotomy.
And I certainly could have offered him that,
and that's where I divide a little
of the internal sphincter muscle.
But we opted for Botox.
And so - and again, he wanted to avoid any kind
of a sphincter cutting, and I'm quite agreeable.
So I usually give 100 units
of Botox - that could be quite high.
Some people who frequently do this may give less dose,
but I have to open the vial anyway
and I haven't found in this group
that I'm causing any incontinence.
I may give a lower dose if I think they have
lower sphincter pressures or I'm concerned.
But in most of my patients who I'm offering,
they really can tolerate the 100 units.
And you'll see when I do the procedure
exactly what that looks like.
Also because I could see that the mucosa
was sort of scarred down and they were far apart, the edges,
I sometimes, and not always, like to lift up
the mucosal edges and just approximate them a little bit.
I'm not trying to close anything.
I can't close the fissure or force it to heal, so to speak.
But I was just trying to approximate the edges
to facilitate healing and by kind of roughing up surfaces
bring in new cellular growth and all of those
good wound-healing things to promote healing.
So when I go to do the key steps in the procedure,
it's really about drawing up the Botox,
and I'll show you how I specifically do it.
And there's really many ways to do it.
So drawing up the Botox, positioning the patient
so that you have a good visualization of the area.
I could do this in lithotomy or prone.
I did his in lithotomy, and the anesthesiologist loves me
because of that because he can protect his airway.
And sometimes I will give a block. In this case, we did.
We did a pudendal block upfront just for some numbing.
And after that we go ahead
and do the injection into the sphincters.
In this specific video, I did a little bit of anatomy.
It shows you some things in case there's any students
or anybody who aren't as familiar with the anal canal.
And then you can clearly visualize the fissure.
Interesting, he had both an anterior
and a posterior fissure.
Most commonly your fissures will be
in the posterior location, but in some anterior.
And lateral fissures are less common
but can see in certain disease states, whatnot.
All right, let's take a look.</p>

<h4>CHAPTER 2</h4>

<p>Okay, so this is 100 of Botox. All right?
And this is what it looks like.
Okay, and it looks like it's empty.
And so there's a little bit of the Botox
right on the bottom there. That's what that is.
And essentially I'm going to dilute it
with some normal saline or mix those two together.
And I choose the volume. I'm gonna use the full 100.
Nobody really knows what the right answer is,
how much Botox to give, but he's had chronic anal fissures,
and I'm gonna give the full 100.
All right, so I'm going to do this.
I'm just gonna draw this up
into my 1-cc syringe that I will be giving.
And at the same time, he's being prepped and draped,
and I'm just giving that, and what that does, it's just gonna...
This really concentrated Botox is now being reconstituted.
And I don't worry as much about the volume
because I plan on just giving the 100 units.
Okay.
When the volume's small, sometimes
it's hard for it to come out.
I have to be underneath the - there we go.
All right, so I'm just drawing up the full 100,
and I'm gonna use that. Okay? Good.
Then we can go ahead to the next step.</p>

<h4>CHAPTER 3</h4>

<p>Okay, so just some basic anatomy.
He is in the lithotomy position.
So genitals are up here, and his legs are up.
And right here you can see,
I'm gonna call this like a little anal skin tag, right?
It's hard to say what's an external hemorrhoid
versus skin tag.
This has kind of like a floppy sort of appearance.
And here you see some prominent internal hemorrhoids.
And then you look in two positions.
I'm now looking here in this anterior location
he's got a little bit of a fissure
and he also has one in this posterior location.
So he has two areas of fissures,
and my plan is to give him some Botox
that I will give in the fissures
and also in all four quadrants actually.
And in the intersphincteric groove.
So next I'm gonna do a digital exam.
So I'm gonna take a little bit of lube.
Thank you very much. All right.
And he's already been anesthetized.
We gave him a pudendal block by injecting on either location.
And he is under a heavy sedation.
Gonna feel here, doing a digital exam.
Let me take an anoscope, please.
I'm gonna take a look on the inside.
I'm gonna take a smaller one to start with
and then maybe you can hand me
the one that's a little bit bigger.
Okay?
Yes. And then we can adjust some light.
Do this and maybe I should make smaller moves.
Can you take that for me? Thank you.
And can you give us some light in here?
And then I'll take a Raytec.
And I want you to just position your hand down,
or maybe you hold the anoscope up like this.
And here, this is the internal sphincter muscle
that is exposed, and you can see kind of
has a white appearance, and this has minimized,
like it's not really healing.
It's not gonna come together anymore.
This has been going on for a long time.
And me just kind of manipulating
and roughing up the tissue a little bit can help.
And then I'm gonna look over here.
Actually I'm gonna change my position this way
so you can get a view here.
And then just from an anatomy perspective,
you can see here's like a hypertrophied
little bit of a papilla here.
And dentate line is somewhere over here.
And then when I'm feeling for the intersphincteric groove,
that is the groove between
the external sphincter and internal sphincter.
And you get a sense, here's the internal sphincter,
and my finger is in the groove.
And this is just to give you a sense of anatomy.
Okay, and then hold this down for a second,
and let's look here, get a really good exam on him.
This also is an area where he hasn't healed,
and he's got this little area here
like it kind of opens and closes, it looks like to me.
Let's see.
No, that looks okay.
Like, there's almost like a little dot here in this location. Okay.</p>

<h4>CHAPTER 4</h4>

<p>Let's start. We'll take the Botox next.
I'm gonna start with the Botox on either side.
So hold this up for me, please.
I'll take the Botox.
So this is the 100 units,
and I'm gonna give it on either side.
.Okay, I'm gonna give a little bit here.
And a little bit here. All right.
I'm gonna give now to this other fissure.
Let's give here and here.
Okay, and then I'm gonna give
in both of these quadrants here -
I'm giving into the intersphincteric groove.
So my finger is in the groove,
I'm pushing the internal sphincter up,
and I'm injecting a little bit on this side.
And then I'm gonna do the same thing on that side.
Actually, what you wanna do is you wanna
kind of come over to my side here.
I don't want you to hurt your hand.
Okay, we'll do this.
Okay, nice.</p>

<h4>CHAPTER 5</h4>

<p>All right, so the Botox is given,
and in many cases that would be enough,
but because this is so chronic,
I wanna just clean the edges up
and bring the tissue a little bit together.
Even though you would never really close a fissure.
Can I have the Bovie, please?
You would never really close, but this has been going on
for so long, but just kind of approximating
might help just a teeny tiny bit.
Just to get some clean tissue on either side.
And then I would say the same thing
over here in this anterior location.
Again, very chronic.
I just want to see if I can't stimulate some growth.
All right.
Okay, great.
Now I'll take that Bovie for a second.
And I'm just gonna...
Okay, can I have a DeBakey?
And actually, the lighted anus scopes are
a little bit better for this
and they're a little bit bigger.
Can I have those, please?
Okay. I've got to see these lighted ones.
Okay. Hook up the light.
And I just wanna stimulate a little bit of...
Tissue growth.
And I'm just gonna approximate.
I wanna see that the edges come together.
So again, I don't really normally close
a little fissure here but this has been going on
for so long, just gonna take a single Chromic and just
approximate it to promote healing more than anything else.
And I lifted it off the edges and stimulate some tissue growth.
I'm gonna take a either a 2-0 or a 3-0 Chromic,
if that's okay. Something...
Yep. So sort of got rid of
that little bit of that white appearance.
I just wanna stimulate tissue growth.
I'm not coning anything else, I'm not dealing with this tag.
I never do that as part of an initial fissure healing,
like even if he complained and said that
that really bothered him, I wouldn't,
it would just cause more pain.
All right, and what I'm doing with the sutures,
I'm just trying to promote bringing the tissue
a little bit together 'cause it's physically apart.
And then...
Lifting the mucosa off.
Yep. Okay.
All right. I'll do that.
Okay, and I'm just...
And I'm not closing the whole thing in any way, shape
or form, just approximating this mucosa.
Okay, and then we'll do the same thing.
We'll take a look on the other side.
It's just to bring them a little bit closer together.
Okay.
Okay. and now we'll switch around.
I'm gonna give this back to you. Great.
And we'll go down to here.
Okay, and we'll take a look at this.
This one's a little bit smaller.
Can I have a probe, please?
Just wanna make sure, like one
of those lacrimal duct probes.
Can I have a smaller one?
I just wanna see.
That doesn't - there's no little fistula or anything.
See how he's got this like,
little kind of mucosal bridge here?
Now it could be...
Let's see.
Like maybe it was a larger one,
and this is the only thing that's left.
So I'm not gonna do much with this one.
This is small. It doesn't look as chronic as the other,
but I am stimulating growth with that. Okay.
And then what I would do next is just some irrigation.
You can take this and unhook that.</p>

<h4>CHAPTER 6</h4>

<p>We'll get rid of the light please.
And we'll do a little bit of irrigation.
And then we gave him - how much local did he get?
Twenty? Okay. So let's give him a little bit more local.
And why don't you go ahead and you can give him
a block again in the two areas so he can tolerate -
we're giving a quarter percent Marcaine,
and he can tolerate a little bit more.
Clean this up a little bit.
Yes. Take this suction.
Now this all looks okay.
And we'll give him a little bit more local.
Oh, there we go.
Yep.
Okay, great.
Okay. And then a little bit more local.
And you can kind of demonstrate what the technique -
you already gave some upfront,
but we could show everybody how you find that.
Go ahead with your technique.
Yep. Go medial.
Nice. Aspirate.
All right. And then give a little bit
and direct it towards the other areas.
Okay. And then we'll give another 10
on the other side, post-op.
Okay.
Okay, perfect. And it's a wrap.
We're just gonna clean him off and we're done. Thank you.</p>

<h4>CHAPTER 7</h4>

<p>That procedure possibly went a little bit slower
than I normally do, and that's because we were videoing
and doing a little bit of education around the anal area.
I did, not just a Botox, but also lifted up a little bit
of those mucosal edges and approximated them.
I did that only in the posterior location,
not in the anterior.
So it's not really always part of my normal routine.
Now as far as post-op goes,
he is encouraged to go back and do the sitz baths.
I tell him to keep his bowel soft.
I talk about using ibuprofen and Tylenol for pain control.
I do give a very short course of narcotic,
just so they have it on hand, but I sort of,
I encourage them to avoid it because it can be constipating.
If they've used the creams before and don't have any issue
with any of the either nifedipine calcium channel blocker,
or nitroglycerin if they have them at home,
I have no issues with them using it.
And then I let everybody know
that you're gonna have bleeding,
you know, that is normal, and you will have pain
because me stimulating that fissure
and manipulating it can be painful.
So it takes a minimum, I would say,
of about six to eight weeks for healing and could be longer.
And if he doesn't improve with the Botox,
and I'm hopeful that he will,
but if he does not, then I will talk to him
about a lateral internal sphincterotomy.
Thank you.</p>


Watch this full-length, narrated surgical video or an anal EUA and Botox injection for chronic anal fissures performed by Dr. Brooke Gurland at Stanford University Medical Center.

Stanford University Medical Center