ANORECTAL FISTULA (FISTULA IN ANO)

Definition:

 Fistula is an abnormal passage from one epithelial surface

to another epithelial surface
 It is a tube like tract with one opening in the anal canal
and the other usually in the perianal skin.
 It is an inflammatory track with one opening in the anal
canal and another in perianal skin
 Fistulas occur spontaneously or secondary to perirectal
abscess.
 Most fistulas originate in the anal crypts at the anorectal
juncture

Goodsall's rule

 If external opening is anterior to an imaginary line drawn

horizontally through anal canal, fistula usually runs
directly into anal canal
 If external opening is posterior to line, the fistula usually
curves to posterior midline of anal canal
 In children, track is usually straight

Classification

1. Intersphincteric
2. Transsphincteric
3. Suprasphincteric
4. Extrasphincteric

Etiology:

 Erosion of anal canal

 Extension from infection from a tear in lining in anal canal
 Infecting organism is commonly Escherichia coli
 Fistulas usually arise spontaneously or occur secondary to
drainage of a perirectal abscess.
 Predisposing causes include Crohn's disease and TB.
 Most fistulas originate in the anorectal crypts; others may
result from diverticulitis, tumors, or trauma.
 Fistulas in infants are congenital and are more common in
boys.
 Rectovaginal fistulas may be secondary to Crohn's
disease, obstetric injuries, radiotherapy, or malignancy.

Risk factors:

 Injection of internal hemorrhoids, puncture wound from

eggshells or fish bones, foreign objects, enema tip injuries
 Ruptured anal hematoma
 Prolapsed internal hemorrhoid
 Acute appendicitis, salpingitis, diverticulitis
 Inflammatory bowel disease (chronic ulcerative colitis,
Crohn disease)
 Previous perirectal abscess
 Radiation treatment to perineum/pelvis

Signs and symptoms:

 Constant or intermittent drainage or discharge

 Firm tender perianal lump
 External anal sphincter pain during and after defecation
 Spasm of external anal sphincter during and after
defecation
 Anal bleeding
 Discoloration of skin surrounding the fistula
 Fistulous opening frequently granulose or scarred
 Possible fever
 A fistula is suggested by the presence of a small external
opening outside the anal verge draining mucus, pus, or
fecal matter.
 A fistula is confirmed by the demonstration of an internal
opening within the anal canal.
 A history of recurrent abscess followed by intermittent or
constant discharge is usual.
 On inspection, one or more secondary openings can be
seen, and a cordlike tract can often be palpated
 A probe inserted into the tract can determine the depth
and direction, and anoscopy with probing may reveal the
primary opening.
 Sigmoidoscopy should follow.
 Hidradenitis suppurativa, pilonidal sinus, dermal
suppurative sinuses, and urethroperineal fistulas must be
differentiated from cryptogenic fistulas
 Fistulas are associated with purulent discharge that may
lead to itching, tenderness, and pain.

Diagnostic procedures:

 Proctoscopy
 Sigmoidoscopy
 Probe inserted into tract to determine its course
 Injection of dilute methylene blue into abscess cavity may
be helpful in demonstrating fistula

Differential diagnosis

 Pilonidal sinus
 Perianal abscess
 Urethroperineal fistulas
 Ischiorectal abscess
 Submucous or high muscular abscess
 Pelvirectal abscess (rare)
 Rule out: Crohn disease; carcinoma; retrorectal tumors

Treatment

 Fistulotomy - surgical incision of entire length of fistula

(unroofing). Mucosal tract may be cauterized or curetted.
Sphincterotomy.
 Fistulectomy - complete excision of tract (rarely indicated
due to extensive tissue loss). Sphincterotomy.
 General anesthesia or regional anesthesia usually
required
 Postoperative - hot sitz baths
 Avoid constipation
 Treatment is by surgical incision or excision under
anesthesia.
 Care must be taken to preserve the anal sphincters.
 The only effective treatment is surgery.
 The primary opening and the entire tract are unroofed and
converted into a "ditch."
 Partial division of the sphincters may be necessary.
 Some degree of incontinence may occur if a considerable
portion of the sphincteric ring is divided.
 Because of delayed wound healing, fistulotomy is
inadvisable in the presence of diarrhea, active ulcerative
colitis, or Crohn's disease.
 Metronidazole or other appropriate antibiotics can be
given to Crohn's disease patients with symptomatic
anorectal fistulas