It currently works like this (UNLESS your local Clinical Commissioning Group refuse to fund Botox (As the Somerset CCG does) for anal fissure):-
Rectogesic / topical glyceryl trinitrate > Normacol or Lactulose + Diltiazem > 2 Rounds of Botox > Lateral Internal Sphincterotomy
You are probably going to have to be highly aggressive, dogmatic and ram it up the doctors arse to get him to skip over the "2 rounds of Botox". Point blank refuse to have Botox and remind him what informed consent means.
I had a very large falling out with some NHS institutionalised Greek CRS at Chelsea and Westminster who REFUSED to do what I asked (and told literally to f**k off) and thus I just went private and got what I wanted; FYI, I don't regret my decision at all.
Don't forget to refer to "Chronic anal fissure: botulinum toxin type A injection" Evidence summary [ESUOM14] from NICE. Print the following page and take it with you: https://www.nice.org.uk/advice/esuom14/ ... w-efficacy
In 3 separate meta-analyses for anal fissure healing, the Cochrane systematic review found botulinum toxin type A injection into the internal sphincter was:
No better than placebo or lidocaine pomade (3 RCTs, 136 patients).
No better or worse than topical glyceryl trinitrate (mostly 0.2%) or isosorbide dinitrate 1% ointment (6 RCTs, 334 patients, including 1 RCT of isosorbide dinitrate).
Not as effective as lateral internal sphincterotomy (5 RCTs, 365 patients).
The doctor is going to remind you that there is a risk of incontinence with LIS which you don't get with a "chemical sphincterotomy". Ultimately thats a risk for you to assume if thats what YOU want.
You should be aware if you are a woman that there is an increased risk of incontinence due to the damage caused by childbirth. If you are young, I wouldn't be too concerned as you are likely to heal well but if you are considerably older, then you may want to give this some thought.
Hope this is helpful to you.
