HNY Central Digital Repository - York

Chronic anal fissure

Botulinum toxin injection is commissioned without need for prior approval for treating adults or children and is expected to be the usual first choice if:

• the anal fissure has not healed or shown progress towards healing after at least 8 weeks of conservative therapy (consisting of a combination of lifestyle advice, stool softening, analgesia and potentially topical GTN or Diltiazem). N.B. Conservative therapy should be repeated for a further 8 weeks if there is progress towards healing within 8 weeks.

Further Botulinum toxin injection is commissioned without need for prior approval for treating adults or children if:

• the anal fissure has not healed or shown progress towards healing 8 weeks after an initial injection OR
• for treatment of a fissure that has recurred after healing

Botulinum toxin injection combined with fissurectomy requires prior approval but is commissioned if:

• the anal fissure has not healed or shown progress towards healing after at least 8 weeks of conservative therapy (consisting of a combination of lifestyle advice, stool softening, analgesia and potentially topical GTN or Diltiazem). N.B. Conservative therapy should be repeated for a further 8 weeks if there is progress towards healing within 8 weeks AND
• the anal fissure has not healed or shown progress towards healing 8 weeks after an initial injection of Botulinum toxin

Lateral internal sphincterotomy requires prior approval but is commissioned if:

• (for adult males) the anal fissure has not healed or shown progress towards healing after at least 8 weeks of conservative therapy (consisting of a combination of lifestyle advice, stool softening, analgesia and potentially topical GTN or Diltiazem). N.B. Conservative therapy should be repeated for a further 8 weeks if there is progress towards healing within 8 weeks

OR

• (for adult females) the anal fissure has not healed or shown progress towards healing after at least 8 weeks of conservative therapy (consisting of a combination of lifestyle advice, stool softening, analgesia and potentially topical GTN or Diltiazem). N.B. Conservative therapy should be repeated for a further 8 weeks if there is progress towards healing within 8 weeks AND
• the anal fissure has not healed or shown progress towards healing after one or more injections of Botulinum toxin

Lateral internal sphincterotomy is not commissioned for children under 16 years of age and therefore should not be routinely offered to patients. Application for funding approval can be made, using the IFR process, by the clinician recommending the intervention, if their assessment is that there are exceptional reasons why their patient could benefit from it.

Conservative therapy will result in healing of most cases of anal fissure.

Botulinum toxin A injection should usually be offered prior to consideration of lateral sphincterotomy, due to the risk of faecal incontinence after surgery.

Combining fissurectomy and Botulinum toxin offers a means of dealing with chronic fibrosis limiting healing and relaxation of any sphincter spasm, thereby theoretically improving outcomes compared with Botulinum toxin alone but the evidence for this is low quality.

Sphincterotomy is a very effective treatment but there is a tradeoff between the undoubted efficacy and the small risk of incontinence. It is likely this risk is less in males with otherwise intact and normally functioning anal sphincters, so it can be considered as first choice for males following failure of conservative treatment. The risks and benefits should be discussed thoroughly.

The risk of incontinence following lateral sphincterotomy is greater in females, because the internal sphincter is shorter in females compared with males. In addition, the female sphincter complex is at risk of compromise by childbirth and menopause. It should therefore be offered with more caution in females and, if undertaken, consideration given to cutting a smaller portion of the sphincter.

Sphincterotomy is not recommended in children due to the potential long-term risk of sphincter damage.

Scenario: Management | Management | Anal fissure | CKS (NICE)

The Association of Coloproctology of Great Britain and Ireland guideline on the management of anal fissure 2023