FISTULA IN ANO

Dr.K.Prathapan WWW.MEDSHORTNOTES.COM

Pictures are taken from various websites.

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Pictures are taken from various websites.

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Pictures are taken from various websites.

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Pictures are taken from various websites.

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Chronic Abnormal communication

Tract is lined by granuation tissue - because of that it not healed! Tract has two openings Internal opening at ano-rectum External opening at either buttock/perineal skin area/ vagina
More common in males ; 30-50 years of age.
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Associated with/Causes:
Fistulae-in-ano are usually ideopathic Occasionally they are a presenting feature of rectal carcinoma Crohn's disease TB Malignancies(Carcinoma) Foreign body Lymphogranuloma venereum Hydradenitis suppurativa Traumatic Ulcerative colitis HIV STERIOD THERAPY RADIATION THERAPY

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Standard classification
1.Subcutaneous -Most common
2.Submucous 3.Low anal

4.High anal
5.Pelvirectal
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Park's classification
1.Intersphincteric - most common 2.Transphincteric
3.Supralevator/Suprasphincteric 4.Anal/ Extrasphincteric

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Park's classification

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Clinical Feature
Dishcharge - purulent or blood stained
pain - may be Hx of perianal abscess (improper Rx) TB fistula do not have induration, most often multiple
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Investigations
Physical exam remains the mainstay of diagnosis
Endoscopic ultrasound

MRI Scan -Gold standard Ix

Fistulogram (Not ideal as it may miss to detect some fistulas in multiple fistula) - done only under Anesthesia. CT Flexible sigmoidoscopy - to find out any underlying pathology +/-

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Treatment
The tracts do not heal on their own, and surgery to correct the problem is necessary.
If low anal fistula (below the internal ring/anal sphincter) Rx is Sx. Fistulectomy/ Fistulotomy

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If high anal fistula(above the internal ring/anal sphincter) - fistulectomy may damage the sphincter. so such surgeries are not done.
Senton wire is used to treat this type of fistula.
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Goodsall's Rule:
Anterior fistulas drain directly Posterior fistulas drain in the manner of Horse shoe.

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In order to help the examiner predict the trajectory of the tract, and probable location of the internal opening, Goodsall's Rule can be applied. With the patient in the lithotomy position:
If the external opening is anterior to an imaginary line drawn horizontally through the anal canal, the fistula usually runs directly into the anal canal.
If the external opening is posterior to the line, the fistula usually curves to the posterior midline of the anal canal.
It should be noted, however, that the further away the external opening is from the anus, the less reliable Goodsall's rule becomes. Additionally, the trajectory of a complex fistula is unpredictable.
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