Published: 2017-05-24

The use of botulinum toxin in children with chronic constipation

Almoutaz A. Eltayeb, Nagla H. Ibrahim, Seham M. Moeen, Hala M. Imam


Background: Conventional therapy of childhood constipation was based on dietary manipulation, stool softeners and oral laxatives. Although these forms of medications are successful in the majority of cases, still small subgroup of patients may fail to respond to this treatment. The aim of this study was to evaluate the role of botulinum toxin in relieving the symptoms of those patients.

Methods: This study was conducted on 20 cases with chronic constipation that fail to respond to conventional medical treatment. Cases under went any previous surgical maneuver will be excluded from study. Anal dilatation was started by Higar dilators then small self-retaining anal retractors were introduced and four injections were made into the four quadrants of the anal canal and rectum at the level of IAS (internal anal sphincter).

Results: twenty cases were included (14 males and 6 females) with age ranged from 8 months to 6 years. The botulinum injection per patients ranged from 1 to 2 injections. The response rate to this treatment was excellent in 6 cases and good in 12 cases and poor in 2 cases. No systemic or local complications occurred in any patients.

Conclusions: botulinum toxin injection could be safe and effective treatment of chronic constipation in infants and children.


Botulinum toxin, Chronic constipation, Internal anal sphincter

Full Text:



Hatch TF. Encopresis and constipation in children. Pediatr Clin North Am. 1988;35:257-80.

Baker SS, Liptak GS, Colletti RB. Constipation in infants and children: evaluation and treatment. A medical position statement of the North American society for pediatric gastroenterology and nutrition. J Pediatr Gastroenterol Nutr. 1996;22:38-44.

Ciamarra P, Nurko S, Barksdale E. Internal anal sphincter achalasia in children: clinical characteristics and treatment with clostridium botulinum toxin. J Pediatr Gastroenterol Nutr. 2003;37:315-9.

Hurst AF. Anal achalasia and megacolon (Hirschsprung’s disease, idiopathic dilation of the colon). Guy’s Hosp Rep. 1934;84:317-50.

Kobayashi H, Hirakawa H, Puri P. Abnormal internal anal sphincter innervation in patients with Hirschsprung’s disease and allied disorders. J Pediatr Surg. 1996;31:794-9.

Oue T, Puri P. Altered intramuscular innervation and synapse formation in internal sphincter achalasia. Pediatr Surg Int. 1999;15:192-4.

Baumgarten HG, Holstein AG, Stelzner F. Nervous elements in the human colon of Hirschsprung’s disease. Vichows Arch Pathol Anat. 1973;358:113-36.

Irani K, Rodriguez L, Doody DP. Botulinum toxin for the treatment of chronic constipation in children with internal anal sphincter dysfunction. Pediatr Surg Int. 2008;24:779-83.

Rodriguez L, Flores A. Internal anal sphincter achalasia: relationship with colonic dysmotility and manometric response to botulinum toxin injection. J Pediatr Gastroenterol Nutr. 2005;41:496.

Freeman NV. Intractable constipation in children treated by forceful anal stretch or anorectal myectomy: preliminary communication. J R Soc Med. 1984;77(3):6-8

De Caluwe D, Yoneda A, Akl U, Puri P. Internal anal sphincter achalasia: outcome after internal sphincter myectomy. J Pediatr Surg. 2001;36:736-8.

Banani AS, Forootan H. Role of anorectal myectomy after failed endorectal pull-through in Hirschsprung’s disease. J Pediatr Surg. 1994;29:1307-9.

Holschneider AM, Shauer A, Meister P. Results of spincteromyotomy in anal-spincter achalasia. Histology and postoperative continence. Chirurg. 1976;47:294-300.

Heikkinen M, Lindahl H, Rintala RJ. Long-term outcome after internal sphincter myectomy for internal sphincter achalasia. Pediatr Surg Int. 2005;21:84-7.

Brown SR, Matabudul Y, Shorthouse AJ. A second case of long-term incontinence following botulinum injection for anal fissure. Colorectal Dis. 2006;8:452-3.

Hoogerwerf WA, Pasricha PJ. Botulinum toxin for spastic gastrointestinal disorders. Baillieres Best Pract Res Clin Gastroenterol. 1999;13:131-43.

Hallan RI, Williams NS, Melling J. Treatment of anismus in intractable constipation with botulinum A toxin. Lancet. 1988;2:714-7.

Friedman A, Diamond M, Johnston MV, Daffner C. Effects of botulinum toxin A on upper limb spasticity in children with cerebral palsy. Am J Phys Med Rehabil. 2000;79:53-9.

Brant CQ, Siqueira ES, Ferrari AP Jr. Botox for oropharyngeal dysphagia: case report of flexible endoscope-guided injection. Dis Esophagus. 1999;12:68-73.

Cuilliere C, Ducrotte P, Zerbib F. Achalasia: outcome of patients treated with intrasphincteric injection of botulinum toxin. Gut. 1997;41:87-92.

Schiano TD, Parkman HP, Miller LS. Use of botulinum toxin in the treatment of achalasia. Dig Dis. 1998;16:14-22.

Wehrmann T, Seifert H, Seipp M. Endoscopic injection of botulinum toxin for biliary sphincter of Oddi dysfunction. Endoscopy.1998;30:702-7.

Jost WH, Schimrigk K. Botulin toxin in therapy of anal fissure. Lancet. 1995;345:188-9.

Shafik A, El-Sibai O. Botulinum toxin in the treatment of non relaxing puborectalis syndrome. Dig Surg. 1998;15:347-51.

Minkes RK, Langer JC. A prospective study of botulinum toxin for internal anal sphincter hypertonicity in children with Hirschsprung’s disease. J Pediatr Surg. 2000;35:1733-6.