Combined treatment approach to chronic anal fissure with associated anal fistula

ANZ J Surg. Jul-Aug 2018;88(7-8):775-778. doi: 10.1111/ans.14292. Epub 2017 Dec 3.


Background: Anal fistula in association with chronic anal fissure (fissure-fistula) is infrequently described. Recognizing this association and managing both components may help prevent some treatment failures seen with chronic anal fissure. This study aims to report on the outcomes of 20 consecutive patients with fissure-fistula managed with fistulotomy and injection of botulinum A toxin.

Methods: The study is a retrospective, observational study, assessing the success of symptom resolution following fistulotomy with botulinum A toxin, in patients identified as having a chronic anal fissure with associated anal fistula. The study included all patients with this condition treated with combination treatment by a single surgeon at a tertiary care hospital between January 2013 and January 2016.

Results: Twenty patients with fissure-fistula treated with fistulotomy and botulinum toxin A were identified. The median cohort age was 44 years (range 25-78), with a predominance of males (80%) and posterior fissure position (80%). The most common presenting symptoms were anal pain (70%), rectal bleeding (55%), anal discharge (35%) and anal pruritus (35%). Mean follow-up was 10.5 weeks and all patients who attended follow-up appointments reported resolution of symptoms. There were no cases of incontinence and none of the cohort required further surgical intervention for the condition.

Conclusion: Chronic anal fissure with associated anal fistula can be successfully managed with fistulotomy and injection of botulinum toxin A. Further studies would be helpful in determining if recognition and management of the fistula component in isolation with fistulotomy is as effective as fistulotomy plus botulinum A toxin.

Keywords: anal fistula; fissure in ano; fissure-fistula.

Publication types

  • Observational Study

MeSH terms

  • Adult
  • Aged
  • Anal Canal / pathology
  • Botulinum Toxins, Type A / administration & dosage
  • Botulinum Toxins, Type A / therapeutic use*
  • Chronic Disease
  • Combined Modality Therapy / methods
  • Female
  • Fissure in Ano / complications
  • Fissure in Ano / drug therapy
  • Fissure in Ano / epidemiology
  • Fissure in Ano / surgery*
  • Humans
  • Male
  • Middle Aged
  • Neuromuscular Agents / administration & dosage
  • Neuromuscular Agents / therapeutic use
  • Rectal Fistula / complications
  • Rectal Fistula / drug therapy
  • Rectal Fistula / epidemiology
  • Rectal Fistula / surgery*
  • Retrospective Studies
  • Treatment Outcome


  • Neuromuscular Agents
  • Botulinum Toxins, Type A