FISTULA-IN-ANO

FISTULA-IN-ANO

A chronic abnormal communication which runs

outwards from the anorectal lumen (the internal
opening) to an external opening on the skin of the
perineum or buttock or vagina (women, rare).
ANATOMY
ANATOMY
 ETIOLOGY

Drainage of anorectal abscess -> results 50%

cure

Remaining 50% -> persistent fistula-in-ano

 ETIOLOGY

Infected crypts (internal opening) and tracks to

the external opening, usually the site of the prior
drainage.

Course: predicted by the anatomy of the previous

abscess

Cryptoglandular in origin (majority)

May be found in specific conditions like:

Trauma
Foreign body
Crohns disease
Malignancy
Radiation
Infections (tuberculosis, actinomycosis, and chlamydia)
Lymphogranuloma venereum
Rectal duplications

*raise suspicion of diagnoses in a complex, recurrent, or

nonhealing fistula.
 DIAGNOSIS

Persistent drainage - external and internal

Indurated - palpable

Goodsalls rule - guide in determining location

 GOODSALLS RULE

Used to indicate the

likely position of the interior
opening according to position
of the exterior opening
(helpful but not infallible).

Probing in an awake
patient is painful, unhelpful,
and dangerous.
 GOODSALLS RULE

EO anterior -> connect to IO

by a short, radical tract
EO posterior -> track in a
curvilinear fashion to the
posterior midline

Exception: if an anterior
external opening is greater
than 3cm from anal margin
then this usually track to the
posterior midline.
 Categorized based on their relationship to the
anal sphincter complex

Treatment is base on this classification

Goal of tx: eradication of sepsis without

sacrificing incontinence
 TYPES OF ANAL FISTULA

Intersphincter fistula
Transsphincter fistula
Suprashincter fistula
Extrasphincter fistula
Complex, nonhealing fistula
 A. INTERSPHINCTERIC FISTULA

Tracks through the distal

internal sphincter to an
external opening near
the anal verge

Tx: fistulotomy (opening

the fistuluos tract),
curettage, and healing
by secondary intention
 B. TRANSSPHINCTERIC FISTULA

From an ischiorectal
abscess
Extends through both the
internal and external
sphincters
Horseshoe: IO in the
posterior midline and
extend anteriorly and
laterally to one or both
ischiorectal spaces
Tx: sphincterotomy or
initial placement of a seton
SETON
Drain placed through a fistula to maintain
drainage and/or induce fibrosis.
Cutting seton: suture or a rubber band that is
placed through the fistula and intermittently
tighten
Noncutting seton: soft plastic drain (often a
vessel loop) placed in the fistula to maintain
drainage

May be left in place for chronic drainage.

HORSESHOE
 C. SUPRASPHINCTERIC FISTULA

Originates from
intersphincteric plane
Tracks up and around
the entire external
sphincter

Tx: seton
 D. EXTRASPHINCTERIC FISTULA

Originates in the rectal

wall
Tracks around both
sphincters to exit laterally,
usually in the ischiorectal
fossa

Tx: depends on both the

anatomy and the etiology
E. COMPLEX, NONHEALING FISTULA

May result from Crohns disease, malignancy,

radiation protitis or unusual infection
PROCTOSCOPY should be performed in ALL cases
(assess the rectal mucosa)
Biopsies should be taken to rule out malignancy
 Higher fistulas tx: endorectal advancement flap

Persistent fistulas: fibrin glue

 External red elevation of granulation tissue w/
or w/o conccurent drainage

Internal more difficult to identify; hydrogen

peroxide or dilute methylene blue