Botox and fissurectomy together

At a glance

Combining botox injection with fissurectomy is an approach some surgeons use for chronic anal fissures that have not responded to conservative treatment. The rationale is straightforward: the fissurectomy removes the chronically damaged tissue, and the botox relaxes the sphincter to create the best possible conditions for the fresh wound to heal.

This guide covers why the combination is used, how it works, and what to expect.

Why the combination makes sense

A chronic anal fissure involves two problems:

1. The fissure itself — which over time develops fibrotic (scarred) edges, sometimes a sentinel pile, and sometimes a hypertrophied anal papilla. This chronic tissue does not heal well on its own.
2. The sphincter spasm — the internal sphincter is in a state of chronic hypertonia (excessive tightness), which reduces blood flow to the area and prevents healing.

Fissurectomy addresses the first problem by excising the chronic tissue and creating a fresh wound. Botox addresses the second by temporarily relaxing the sphincter. Together, they tackle both issues simultaneously.

The procedure

The combined procedure is typically done under general anaesthesia as a day case:

1. Botox is injected into the internal anal sphincter — typically on each side
2. The chronic fissure tissue is excised — this includes the fibrotic fissure edges, sentinel pile if present, and any hypertrophied papilla
3. The wound is left open to heal by secondary intention
4. You go home the same day in most cases

The procedure usually takes less than 30 minutes.

Recovery

Recovery follows a similar pattern to fissurectomy alone, with one important difference: the botox provides sphincter relaxation during the healing window, which most people describe as making recovery more manageable.

The first week

• Pain with bowel movements — present but often less severe than expected, thanks to the botox
• The wound is open and draining — blood-tinged fluid is normal
• Sitz baths after every bowel movement
• Stool softeners and fibre are essential
• Rest and limited activity

Weeks two to six

• Gradual wound healing — granulation tissue fills in from the base
• Pain continues to decrease
• The botox is at full effect, keeping the sphincter relaxed
• This is the critical healing window — maintaining self-care is essential

Weeks six to twelve

• The wound is significantly smaller and approaching full closure
• The botox begins to wear off (typically around month three to four)
• By the time sphincter tone returns, the wound should be well healed
• Follow-up with your surgeon confirms progress

Who it is suitable for

This combination is typically considered for:

• Chronic fissures with fibrosis, sentinel pile, or other chronic tissue changes
• People who want to avoid LIS and the small but permanent incontinence risk
• Failed conservative treatment — topical treatments and/or botox alone were insufficient
• People where sphincter-sparing is a priority

Compared to other options

These are general figures from published literature. Individual outcomes depend on many factors.

Questions to ask your surgeon

• Why are you recommending the combined approach over LIS?
• What dose of botox will you use?
• How does your personal success rate compare with published figures?
• What should I expect in terms of pain management?
• When will my first follow-up be?
• What are the signs of complications I should watch for?