Perianal abscess & Anal

fistulae
By
Rajeev Suryavanshi
Dept of General Surgery.

Perianal abscess
Definition Infection of the soft tissue
surrounding the anal canal, with
formation of discrete abscess cavity.
Often cavity is associated with
fistulous tract.

Anorectal anatomy
Rectum develops from hind gut at 6

weeks
Anal canal formed at 8 weeks ectoderm.
Dentate line transition from endo to ecto.
Rectum has inner circular.
outer longitudinal.
Anal canal 4cm, pelvic diaphragm to
anal verge.

Anatomy
External Sphincter- U shaped , continuation of levator ani
- deep segment is continuous with puborectalis
muscle and forms anorectal ring felt on DRE.
- striated muscle
- voluntary control
- 3 components - sub mucous, superficial and
deep.

Anatomy Internal sphincter- smooth muscle

- autonomic control
- extension of
circular muscles of
rectum.
- contracted at rest.

Anatomy
4-8 anal glands

drained by respective
crypts, at dentate line.
Gland body lies in
intersphincteric plane.
Anal gland function is
lubrication.
Columns of Morgagni
8-14 long mucosal
fold.

Pathophysiology
Infection starts in crypto glandular

epithelium lining the anal canal.

Internal anal sphincter a barrier to infection
passing from gut to deep perirectal tissue.
Duct of Anal gland penetrate internal
sphincter into intersphincteric space.
Once infection sets in intersphincteric
space it can spread further.

Pathophysiology
Glandular secretion
stasis

Infection &
suppuration

Anal crypts
obstruction

abscess
formation

Frequency
Common in 3rd and 4th decade of life
Male > female (2:1)
30% present with previous episodes.
Increase incidence during summer and
spring.
Common in infants , poorly understood
mechanism , fairly benign and majority
settle with simple drainage.

Etiology
Abscess initially forms in the

intersphincteric space and spreads

along adjacent potential spaces.
Common organisms* E.Coli
* Enterococcus species
* Bacteroides species.

Etiology
Less common causes Crohns Disease.
Cancer.
Tuberculosis.
Trauma.
Leukemia.
Lymphoma.

Clinical features
Symptoms Pain Perianal
movement
pressure
Pruritis
Generally unwell.
Fever
Chill and rigor.

Signs Swelling
Cellulitis
induration
Fluctuation
Subcutaneous mass,
near Perianal orifice.
DRE- fluctuation at
times in ischorectal.

Classification of Anorectal
abscesses
60%
Perianal
20%
Ischiorectal
Intersphincteric 5%
4%
Supralevator
1%
Submucosal

Classification
Perianal pus underneath skin of anal

canal, do not traverse external sphincter.

Ischiorectal suppuration traversing
external sphincter into Ischiorectal space.
Intersphincteric suppuration between
external and internal sphincter.
Horse shoe abscess - uncommon
circumferential infiltration of pus with in
intersphincteric space.

Investigation & Imaging

No specific test required
Patients with diabetes ,

immunosuppresed will need lab

evaluation.
Imaging role in only deep seated,
Supralevator or intersphincteric
abscesses.
CT Scan , MRI or Anal ultrasonography.

Management
Mainly surgical
Antibiotics in diabetics &

immunocompromised individuals.
Early drainage is indicated as delay can cause* prolong infection
* tissue destruction
* chances of sphincter dysfunction
* Promote fistula formation.

Management
1. Perianal abscess - superficial ones

can be drained in office under L.A

Incision
Pus culture & sensitivity
Packing with iodophor gauge.
Laxative & Sitz bath.
Review & follow up 2-3 weeks to see
for healing & fistula formation.

Management
Organism culture is important.
Abscess with intestinal organisms have a

40% chance of forming fistula.

Cultures growing Staphylococcus species
Perianal skin infection and have no risk
of subsequent fistula formation.
2. Ischiorectal abscess GA
Cruciate incision over max swelling.

Management

Pus drained and cultured

Disrupt loculi
Drain placed.
3. Intersphincteric abscess Transverse incision in anal canal
below the dentate line, posteriorly.
Abscess opened, leave drain,
prevents premature closure.

Management
4. Supralevator abscess Location & etiology determines its

drainage technique.
Evaluation with CT Scan & MRI .
Abdominal pathology deal with cause
If extension of Ischiorectal drainage
through the space indicated.
Anterior Supralevator are superficial and
more common in females.- transanal or
transvaginal approach can be used.

Anal fistula- Fistula-in-ano

Definition Hollow tract, lined with granulation
tissue connecting a primary opening
inside the anal canal to a secondary
opening in the Perianal skin.
Treatment of fistula-in-ano can be
challenging.

Fistula-in-ano
Magnitude of problemPrevalence rate - 8.6 / 100,000
population.

Male : Female = 2 : 1
Mean age = 38 Years.

Etiology
* Following Anorectal abscess.
* Other causes
- Sec. to trauma
- Crohns disease
- Anal fissures
- Carcinoma
- Radiation therapy
- Tuberculosis, Actinomycosis.

Pathophysiology

Fistula formation

Anal gland infection

Drainage self/ surgery

Perianal abscess

Clinical presentation
History Recurrent Swelling,

Discharge, Pain and Surgery for an

Abscess.
Symptoms
- Perianal discharge
- Pain
- Swelling
- Bleeding
- External opening

Clinical presentation
Past medical history* Inflammatory bowel disease.
* Diverticulitis
* Previous pelvic radiation
* Tuberculosis
* Steroids therapy
* HIV infection

Clinical presentations
Physical examination * Look at entire perineum,
* An open sinus or elevation of granulation
tissue.
* Discharge may be seen.
* DRE- fibrous cord, or cord beneath the skin.
* Voluntary squeeze pressures & sphincter
tone
should be assessed.

Goodsall rule Perianal

fistula
Transverse line drawn

across the anal verge

Anterior external
opening associated
with straight tract to
anal canal or rectum.
Posterior ext. opening
follows curved tract,
entering posterior
midline.
Exception 3cm

Park Classification systemA. Intersphincteric

B. Transsphincteric
C. Suprasphincteric
D. Extrasphincteric

Fistula-in-ano

Fistula with probe

Fistula-in-ano
A. Intersphincteric Via internal
sphincter to
intersphincteric
space then to
perineum.
70%

B. Transsphincteric Via internal and

external sphincter
into Ischiorectal
fossa and then to
perineum.
25%

Fistula-in-ano

Transsphincteric
fistula.

Fistula-in-ano
C. Suprasphincteric
Via intersphincteric
space superiorly to
above puborectalis
muscle into
Ischiorectal fossa
then perineum.
5%

D. Extrasphincteric From Perianal skin

through levator ani
muscles to the
rectal wall
completely outside
sphincter
mechanism.
<1%

Imaging Studies
Not indicated for routine evaluation
Performed when external opening is

difficult to identify, recurrent or multiple

fistulae.
1. Fistulography- involves injection of contrast via the
opening and taking images in different
planes.
- 15- 48% accuracy.

Imaging studies
2. Endo Anorectal Ultrasonography - Transducer 7-10 MHz.
- Installation of H2O2 can help location of
internal opening .
- not widely used.
3. MRI - Study of choice
- 80-90% concordance with oper.finding.
- good for primary course and sec
extensions.

Imaging
4. CT Scan
- Good for perirectal inflammation
disease, delineating fluid pockets.
- Needs oral and rectal contrast.
- poor delineation of muscular anatomy.
5. Barium enema / Small bowel series - Useful in multiple fistulae or recurrent
disease, also to rule out IBD.

fistula imaging

MRI showing

intersphincteric
fistula anteriorly
Prm-puborectalis
muscle.

Other investigations
Anal Manometry-

Pressure evaluation of sphincter mechanism

help in some cases - Decreased tone in preop evaluation
- previous fistulectomy
- obstetrical trauma
- high transsphincteric or suprasphincteric fistula
- very elderly patient.
If decreased, avoid - surgical division of any
portion of sphincter.

Diagnostic procedures
A. E U A Examination of perineum, DRE, anoscopy.
To look for internal opening techniques- Inject - H2O2, Milk, Dilute methylene blue
- Traction on external opening may help
- Probing gently can help.
B. Proctosigmodoscopy / Colonoscopy Rigid sigmoidoscopy to rule rectal disease.

Management
1. Fistulotomy / Fistulectomy - laying open technique is useful in 85-95% of
primary fistulae.
- overlying skin, subcutaneous tissue, internal
sphincter divided with electrocautry, curette
tract to remove granulation tissue.
- complete fistulectomy creates bigger wound
with no advantage in minimizing recurrence.
- perform biopsy of firm or suggestive tissue.

Management
2. Seton Placement
- Alone, in combination with fistulectomy or
as a stage procedureUseful in
Complex fistulae
Recurrent fistulae after fistulectomy
Anterior fistulae in females
Poor preop sphincter pressure.
Immunosuppresed patients.

Seton placement Seton defines sphincter muscles

Promotes - Drainage
- Fibrosis.
Material used- Silk suture
- Silastic vessel markers
- Rubber bands

Seton
1. Single stage (cutting)
Passing seton through

tract and tightened

down with separate
silk tie.
Fibrosis above
sphincter muscles
seen as it cuts the
muscles.
Tightened in office
over weeks

2. Two Stage (draining /

fibrosis)
Pass seton through deep
portion of external
sphincter.
Seton left loose here.
When superficial wound
is healed , seton bound
muscle is divided.
Studies support 2 stage
procedure using 0nylon.

3.Mucosal Advancement
Flap In chronic high fistula , indication same as

seton.
Total fistulectomy , removal of primary and
secondary tract with internal opening
Rectal mucomuscular flap is raised .
Internal muscle defect is closed with
absorbable suture and flap is sewn down
over internal opening.
Single stage procedure
Poor success in Acute infection and Crohns.

Follow up
Sitz bath
Analgesia
Stool bulk agents (bran)
Frequent office visits to ensure
healing.
Healing in 6 weeks.

Complications
Early Urinary retention
Bleeding
Fecal impaction
Thrombosed
hemorrhoids.

Delayed Recurrence
Incontinence stool)
Anal stenosis
Delayed wound
healing.

Outcome & Prognosis

Following

Rate of
Recurrence

Incontinence
of stool

Standard
Fistulotomy

0 -18%

3 -7 %

Seton

0 17%

0 -17 %

Mucosal
advancement
flap

1- 10%

6 8%

Newer Developments
1. Biotechnical advances are

producing many new tissue

adhesives.
- some reports suggest 60% success
with 1 year follow-up ,using fibrin
glue in treatment of fistula-in-ano.
- less invasive & postop morbidity.

Newer developments
Recurrent fistulous disease to rectum

and perineum with Anorectal sepsis

indication for surgery
Recent reports suggest 50-60%
response rate with infiximab - the
monoclonal antibody to TNF for
Perianal fistulae.

Thank you