10/1/2017 Anal Fistulas and Fissures: Background, Pathophysiology and Etiology, Epidemiology

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Anal Fistulas and Fissures

Updated: Dec 29, 2016
Author: Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE; Chief Editor: Barry E
Brenner, MD, PhD, FACEP more...

OVERVIEW

Background
An anal fissure is a superficial linear tear in the anoderm that is distal to the dentate line. Anal
fissures are often associated with local trauma such as the passage of hard stools or anal trauma,
but can also be due to secondary causes such as inflammatory bowel disease. Anal fissures are
among the most common anorectal disorders in the pediatric population. Adults are also affected,
although it is thought to be underreported in the adult population.

Fissures are defined as acute if present for less than 8 weeks, and they are defined as chronic if
present for more than at 8-12 weeks weeks. [1]

An anal fistula is an inflammatory tract between the anal canal and the skin. The 4 categories of
fistulas, based on the relationship of fistula to sphincter muscles, are intersphincteric,
transsphincteric, suprasphincteric, and extrasphincteric. [2]

An anal fistula can be categorized as either simple or complex. A simple anal fistula includes low
transsphincteric and intersphincteric fistulas that cross 30% of the external sphincter. Fistulas are
complex if the primary track includes high transsphincteric fistulas with or without a high blind tract,
suprasphincteric and extrasphincteric fistulas, horseshoe fistulas, multiple tracks, anteriorly lying
track in a female patient, and those associated with inflammatory bowel disease, radiation,
malignancy, preexisting incontinence, or chronic diarrhea. Note the image below.

Anal fistulas and fissures. This patient reported constipation.

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Pathophysiology and Etiology

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Anal fissure

In anal fissures, the anus distal to the dentate line is involved. About 90% of anal fissures occur in
the posterior midline. Ten percent are found in the anterior midline, more commonly in women.
Only 1% occur off midline.

While the exact etiology is often unknown, passage of hard stools and anal trauma are often
associated with anal fissures. Other causes of anal fissures can be observed in patients with
chronic diarrhea, during childbirth, and those with a habitual use of cathartics. When an anal
fissure occurs in an atypical location, it may be associated with syphilis and other sexually
transmitted diseases, tuberculosis, [3] leukemia, [4] inflammatory bowel disease such as Crohn
disease, previous anal surgery, HIV disease, and anal cancer. Once a fissure is formed, ongoing
pain can cause the internal analsphincter to spasm (hypertonicity), which causes the wound edges
of the fissure to pull apart, impairing healing. Local ischemia is also thought to contribute to anal
fistulas, especially in the posterior quadrant where blood flow is significantly less than other
quadrants. As the anal sphincter continues to spasm, increased pressures are thought to further
impede blood flow. [5, 1]

Evidence suggests that blood flow to the anal canal and internal anal sphincter tone play a role in
the development and healing of anal fissures. Decreased blood flow has been described in
chronic, nonhealing fissures. Hypertonicity of the internal sphincter may also cause decreased
blood flow in the area of a fissure. [6, 7, 8]

Anal fistula

Most anal fistulas originate in anal crypts, which become infected, with ensuing abscess formation.
When the abscess is opened or when it ruptures, a fistula is formed. An anal fistula can have
multiple accessory tracts complicating its anatomy.

Other causes of anal fistulas include opened perianal or ischiorectal abscesses, which drain
spontaneously through these fistulous tracts. Fistulas are also found in patients with inflammatory
bowel disease, particularly Crohn disease. [9] The incidence of fissures in Crohn disease is 30-
50%. Perianal activity often parallels abdominal disease activity, but it may occasionally be the
primary site of active disease.

Anal fistulas can also be associated with diverticulitis, foreign-body reactions, actinomycosis,
chlamydia, lymphogranuloma venereum (LGV), syphilis, tuberculosis, [3] radiation exposure, and
HIV disease. Approximately 30% of patients with HIV disease develop anorectal abscesses and
fistulas.

Anal fistulas are classified into the following 4 general types:

Intersphincteric - Through the dentate line to the anal verge, tracking along the
intersphincteric plane, ending in the perianal skin
Transsphincteric - Through the external sphincter into the ischiorectal fossa, encompassing a
portion of the internal and external sphincter, ending in the skin overlying buttocks
Suprasphincteric - Through the anal crypt and encircling the entire sphincter, ending in the
ischiorectal fossa
Extrasphincteric - Starting high in the anal canal, encompassing the entire sphincter and
ending in the skin overlying the buttocks

Epidemiology
Anal fissures affect males and females equally; however, an anterior fissure is more likely to
develop in women (25%) than in men (8%). [5] Although anal fissures are the most common cause
of rectal bleeding in infants, they are primarily seen in young adults. Eighty-seven percent of
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10/1/2017 Anal Fistulas and Fissures: Background, Pathophysiology and Etiology, Epidemiology

people with a chronic anal fissure are between the ages of 20 and 60 years. Anal fissures in
children may indicate sexual abuse.

Anal fistulas are a complication of anorectal abscesses, which are more common in women than in
men. For reasons of intrinsic anatomy, rectovaginal fistulas are found only in women.
Approximately 30-50% of patients with an anorectal abscess form an anal fistula. [10] and
approximately 80% of anal fistulas arise from anorectal infection. [11]

Prognosis
Approximately half of uncomplicated fissures resolve in 2-4 weeks with supportive care. [1] Fissures
that heal with conservative treatment can recur, depending on the type of treatment the patient has
undergone (ranging from 16% to more than 50%). [5] Chronic anal fissures frequently require
surgical treatment.

Surgical treatment of anal fissures is associated with some degree of incontinence in

approximately 14% of patients. [12]

Prognosis for fistulas is excellent after surgery, with recurrence rates around 7-21% depending on
the complexity and location of the fistula. [11, 13] Use of fibrin glue or fistula plug has variable
success rates.

Clinical Presentation

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