FISTULA IN-ANO

Definition Physical examination

 An anorectal fistula (Fistula-in-Ano) is an abnormal
communication between the anus and the perianal skin.
 Fistula is an abnormal passage from one epithelial surface to
another epithelial surface
 It occurs as 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 from the same
primary opening.
Sex and Age
The male-to-female ratio approx. 2:1
The mean age of patients is 38 years.
Etiology:
-Fistula-in-ano is nearly always caused by a previous anorectal
abscess.
-Anal canal glands situated at the dentate line afford a path
for infecting organisms to reach the intramuscular spaces.
Other predisposing factors(anal pathology +others)
1) Trauma
2) Crohn disease
3) Anal fissures
4) Anorectal Carcinoma
5) Radiation therapy
6) Infection -actinomycoses, tuberculosis, and chlamydial
infections.
7) Prolapsed internal hemorrhoid
8) Acute appendicitis, salpingitis, diverticulitis
9) Immunosuppression
Physical examination findings remain the mainstay of
diagnosis.
 The examiner should observe the entire perineum
 external opening that appears as an open sinus or
elevation of granulation tissue
 Spontaneous discharge via the external opening may be
apparent or expressible upon digital rectal examination.
DRE
 External Anal sphincter tone
 Tenderness on examination
 Fibrous tract or cord beneath the skin.
 Bogginess-any abscess.
 Lateral or posterior induration suggests deep postanal
or ischiorectal extension.
Differential diagnoses
The following do not communicate with the anal canal:
 Perianal abscess
 Urethroperineal fistulas
 Abcesses-Ischiorectal abscess,Submucous or high
muscular abscess, Pelvirectal abscess (rare)
 Crohn's disease
 Carcinoma
 Retrorectal tumors
 Hidradenitis suppurativa is chronic suppurative
folliculitis of apocrine sweat-gland–bearing skin of the
perianal, axillary, and genital areas or under the
breasts, developing after puberty and producing
abscesses or sinuses with scarring.
 Infected inclusion cysts

Pathophysiology:  Pilonidal disease- a fistula or pit in the sacral region,

The cryptoglandular hypothesis communicating with the exterior, containing hair which
may act as a foreign body producing chronic
 The infection begins in cryptoglandular situated at the inflammation.
dentate line in the anal canal and progresses into the  Bartholin gland abscess in females
muscular wall of the anal sphincters to cause an
anorectal abscess. The Goodsall Rule
 Following surgical or spontaneous drainage in the perianal Help to anticipate the anatomy of fistula-in-ano.
skin, occasionally a granulation tissue–lined tract is left The rule states that fistulae with an external opening anterior to a
behind, forming the fistula in-ano which causes recurrent plane passing transversely through the center of the anus will
symptoms. follow a straight radial course to the dentate line. Fistulae with
their openings posterior to this line will follow a curved course to
Clinical presentation the posterior midline.
History (in order of prevalence)  In children, track is usually straight
1) Perianal discharge-intermittent or constant
2) Perianal pain-worse during defecation, may be constant Classification of fistula in-ano
3) Swelling /lump in the perianal area Parks classification system (all are in relation to the sphincters)
The Parks classification system defines 4 types of fistula-in-ano
4) Bleeding in the perianal area that result from cryptoglandular infections.
5) Diarrhea 1.Intersphincteric-commonest-70%
6) Discoloration of skin surrounding the fistula Common course - Via internal sphincter to the intersphincteric
7) External opening in the perianal discharging space and then to the perineum. They result from perianal
8) Fever abscesses
2. Transsphincteric -25%
Past medical history Common course - Low via internal and external sphincters into
Important points in the history that may suggest a complex fistula the ischiorectal fossa and then to the perineum. Originate from
include the following: ischiorectal abscesses
-Inflammatory bowel disease 3.Suprasphincteric -5%
-Diverticulitis Common course - Via intersphincteric space superiorly to above
-History of trauma puborectalis muscle into ischiorectal fossa and then to
-Previous radiation therapy for prostate or rectal cancer perineum. Result from supralevator abscesses
-Tuberculosis 4. Extrasphincteric-1%
-Immune suppression-Steroid therapy, HIV infection Bypass the anal canal and sphincter mechanism, passing
through the ischiorectal fossa and levator ani muscle, and open
Review of symptoms high in the rectum
-Abdominal pain
-Weight loss
-Change in bowel habits

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Current procedural terminology codes classification
1.Subcutaneous
2.Submuscular (intersphincteric, low transsphincteric)
3.Complex, recurrent (high transsphincteric, suprasphincteric and
extrasphincteric, multiple tracts, recurrent)
3.Second stage
Investigations
Lab Studies:
No specific laboratory studies are required; the normal
preoperative studies are performed based on age and
comorbidities.
Imaging Studies:
These are not performed for routine fistula evaluation. They can
be helpful when the primary opening is difficult to identify or in the
case of recurrent or multiple fistulae to identify secondary tracts
or missed primary openings.
1. Fistulography
This involves injection of contrast via the internal opening, which
is followed by anteroposterior, lateral, and oblique x-ray images
to outline the course of the fistula tract.
2.Endoanal/endorectal ultrasound
To help define muscular anatomy differentiating intersphincteric
from transsphincteric lesions.
3. MRI
MRI is becoming the study of choice when evaluating complex
fistulae
4.CT scan
A CT scan is more helpful in the setting of perirectal inflammatory
disease than in the setting of small fistulae because it is better for
delineating fluid pockets that require drainage than for small
fistulae
Procedures
Proctosigmoidoscopy/colonoscopy
Rigid sigmoidoscopy can be performed at the initial evaluation to
help rule out any associated disease process in the rectum.
MANAGEMENT
Medical
Broad spectrum antibiotics
Surgery
Fistulotomy - Incision or surgical enlargement of a fistula
 The laying-open technique (fistulotomy) is useful for 85-95%
of primary fistulae (ie, submucosal, intersphincteric, low
transsphincteric).
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 A probe is passed into the tract through the external and
internal openings.
 The overlying skin, subcutaneous tissue, and internal
sphincter muscle are divided with a knife or electrocautery,
thereby opening the entire fibrous tract.
 If the fistula tract courses higher into the sphincter
mechanism, seton placement should be performed.
Fistulectomy-Excision of a fistula
 As above with Curettage performed to remove all granulation
tissue in the tract base.
 Complete fistulectomy creates larger wounds that take
longer to heal and offers no recurrence advantage over
fistulotomy.
 Perform a biopsy on any firm, suggestive tissue
Seton placement
A Seton can be placed alone, combined with fistulotomy, or in a
staged fashion. This technique indicated in:
1.Complex fistulae -high transsphincteric, suprasphincteric
,extrasphincteric, multiple fistulae
2.Recurrent fistulae after previous fistulotomy
3.Anterior fistulae in female patients
4.Poor preoperative sphincter pressures
5.Patients with Crohn disease or patients who are
immunosuppressed
Setons have 2 purposes beyond giving a visual identification of
the amount of sphincter muscle involved.
(1) drain and promote fibrosis
(2) Cut through the fistula.
Setons can be made from large silk suture, silastic vessel
markers, or rubber bands that are threaded through the fistula
tract.
Procedure
-Pass the seton through the fistula tract around the deep external
sphincter after opening the skin, subcutaneous tissue, internal
sphincter muscle, and subcutaneous external sphincter muscle.
-The seton is tightened down and secured with a separate silk
tie.
-With time, fibrosis occurs above the seton as it gradually cuts
through the sphincter muscles and essentially exteriorizes the
tract.
-The seton is tightened on subsequent office visits until it is
pulled through over 6-8 weeks.
In complex multiple fistula
-Colostomy may be fashioned
-Posterior Sagittal anorectoplasty done for multiple fistulectomies
Preoperative details:
-Rectal irrigation with enemas should be performed on the
morning of the operation.
-Administer preoperative antibiotics.
-Prone jackknife position with buttocks apart is the most
advantageous position
Post-operative management
1. Sitz baths, analgesics, and stool bulking agents (eg, bran,
psyllium products).
2. Internal wound should not close prematurely, causing a
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recurrent fistula. Digital examination findings can help distinguish
early fibrosis. 3.Wound healing usually occurs within 6 weeks

COMPLICATIONS
Early postoperative
 Urinary retention
 Bleeding
 Fecal impaction
 Thrombosed hemorrhoids

Delayed postoperative
 Recurrence
 Incontinence (stool)
 Anal stenosis: The healing process causes fibrosis of
the anal canal. Bulking agents for stool help prevent
narrowing.
 Delayed wound healing: Complete healing occurs by 12
weeks unless an underlying disease process is present
(ie, recurrence, Crohn disease)

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