Fistula in Ano Symptoms Diagnosis and Treatment
A fistula-in-ano is a hollow tract lined with granulation tissue, connecting a primary opening inside the anal canal to a secondary opening in the perianal skin. Secondary tracts may be multiple and can extend from the same primary opening
A fistula is an abnormal communication between two epithelial surfaces.
An epithelial surface is any part of the body that is covered by a special type of
cells called “the epithelium”. Examples of such surfaces are the skin, the mucosa
of the mouth, the mucosa of the bowel, the mucosa of the anal canal, the vagina
etc.
A fistula in ano is an abnormal sinus track (or a fine tube), between the skin
(external orifice of the fistula) and either an abscess or the anus / rectum
(internal orifice of the fistula).
There is a relation between a perianal abscess and a fistula in ano: almost
always a fistula develops as a result of an abscess.
As we describe in the chapter of “perianal abscess” any abscess tries to drain
itself automatically to the nearest exit point. This could be the interior of the
anus/rectum or the skin.
Once it is formed, a fistula will stay in place for as long as there is pus that
requires drainage through its track. Therefore a chronic infection that drags
on also perpetuates the related fistula.
An epithelial surface is any part of the body that is covered by a special type of
cells called “the epithelium”. Examples of such surfaces are the skin, the mucosa
of the mouth, the mucosa of the bowel, the mucosa of the anal canal, the vagina
etc.
A fistula in ano is an abnormal sinus track (or a fine tube), between the skin
(external orifice of the fistula) and either an abscess or the anus / rectum
(internal orifice of the fistula).
There is a relation between a perianal abscess and a fistula in ano: almost
always a fistula develops as a result of an abscess.
As we describe in the chapter of “perianal abscess” any abscess tries to drain
itself automatically to the nearest exit point. This could be the interior of the
anus/rectum or the skin.
Once it is formed, a fistula will stay in place for as long as there is pus that
requires drainage through its track. Therefore a chronic infection that drags
on also perpetuates the related fistula.
Gallery Images of Fistula In Ano --
Fistula in Ano
Symptoms
Anal fistulae can present with many different symptoms:
- Pain
- Discharge — either bloody or purulent
- Pruritus ani — itching
- Systemic symptoms if abscess becomes infected
[edit]Diagnosis
Diagnosis is by examination, either in an outpatient setting or under anaesthesia (referred to as EUA — Examination Under Anaesthesia). The examination can be an anoscopy.
Possible findings:
- The opening of the fistula onto the skin may be seen
- The area may be painful on examination
- There may be redness
- An area of induration may be felt — thickening due to chronic infection
- A discharge may be seen
- It may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula
Pilonidal cysts/sinuses are another condition in which infected perianal "holes" or openings may appear
Diagnosis of Fistula in Ano
Most fistulas have an easily identifiable external orifice which discharges pus or
bloody fluid. However this orifice may close from time to time and on first
examination may be missed. A lump of the skin around the anus often hides an
underlying fistula orifice.
The methods to diagnose and image the fistula are:
Most fistulas have an easily identifiable external orifice which discharges pus or
bloody fluid. However this orifice may close from time to time and on first
examination may be missed. A lump of the skin around the anus often hides an
underlying fistula orifice.
The methods to diagnose and image the fistula are:
- Examination under Anaesthetic (EUA)
- MRI Scan of the perineum
- Endorectal Ultrasound
Surgical Treatment of Fistula in Ano
- Fistulotomy: laying open of the fistula track.
- Fistulectomy: excision of the fistula track
- Advancement flap repair: this is a complex form of surgery, performed only by specialist colorectal surgeons and it consists of creation of a “flap” of rectal tissue which is used to cover the internal orifice of the fistula. It is performed only for persistent high fistulas and it carries a high risk of incontinence.
After either fistulotomy or fistulectomy there is an open wound left which is
packed for a few days. Nursing care is required for a varied period of time which
depends on the size of the wound and the degree of associated infection.
At some point dressings stop being necessary and the patient can continue
treatment with salt baths.
There are two main complications after any surgery for fistula in ano:a. Recurrence: in many cases a fistula will recur despite surgery. This is
because, as explained above, infections in this area are difficult to eradicate and
surgery is limited by the risk of incontinence.
Recurrence is common and can sometimes be very frustrating for both patient
and surgeon. It is not unusual for some unfortunate patients to have to undergo
many repeat examinations under anaesthetic (EUA) and fistulotomies. The
placement of seton helps with keeping the local infection under control without
having to do many repeat surgical drainages.
b. Incontinence: Any type of surgery in the anal area can result in
incontinence. This can be mild incontinence (for flatus only) or more severe
(incontinence for stools). Incontinence is the result of either surgical damage or
severe infection which destroys the sphincter.
The risk of incontinence has to be discussed with all patients prior to surgery.
This risk is usually quite low (around 2-5%) but in case of complex high fistulas
can be higher. Also the “flap advancement” operation may have a much higher
risk of incontinence (around 20%).
Colostomy is sometimes necessary as a temporary measure if the infection
does not settle. A colostomy for a few months diverts the flow of the faeces from
the anus and allows for the sepsis to be treated. It can then be closed. Very few
patients with fistula will need a colostomy.
Fibrin glue is a new treatment that has been useful in some cases. A biological
glue is prepared either from the patient’s blood or from bovine blood (the latter is
commercially available). Fibrin glue contains natural blood clotting products and
when applied it forms a plug that seals off the fistula. Although some satisfactory
results have been reported, its usefulness is limited by infection. In the presence
of infection the glue fails to close the fistula.
Factors predisposing to fistula in ano are Crohn’s disease, radiotherapy, cancer etc., however in most cases no specific cause is found.
The life with a fistula can be normal if sepsis/infection is avoided. A patient can
wear the seton for many months or a year or two without severe symptoms apart
from occasional small discharge. Hot salt baths help to soothen and irrigate the
area.
Although surgery is absolutely necessary at some point for every fistula, multiple
operations without a specific aim, such as draining sepsis or laying open the
complete fistula, do no always help and can lead to incontinence.
An MRI of the perineum-anus should be performed whenever new symptoms
or serious flare-ups occur in order to identify new abscess cavities.
Most fistulas eventually settle, however they may take a long time until
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Kshar-Sutra Is an Ayurvedic surgical process done by kshar-sutra ligation of fistula witch remove it completely
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