Anal fistula is a common condition affecting the rectum and anus, estimated to affect 1.2 to 2.8 out of every 10,000 people. The condition is twice as common in males as females, and of the people who develop anal gland inflammation, half will develop an anal fistula. Anal fistula is a condition that requires accurate diagnosis and prompt treatment, as surgery is the most effective treatment to get rid of this issue once and for all.
What is an anal fistula?
An anal fistula is an abnormal tunnel that develops between the anus and the surrounding skin, sometimes known as a perianal fistula. It usually forms at the top of the anus, where the anal glands are located. When these glands become infected with an abscess, the leakage of pus from the abscess may cause a small channel to form between the anus and the skin – the fistula.
This condition causes uncomfortable symptoms such as pain and skin irritation. Usually does not improve on its own and does not heal without medical intervention; surgery is the most effective anal fistula treatment.
What does an anal fistula look like?
An anal fistula looks like a hole in the skin near the anal area; this hole is the outer part of a tunnel that extends inward and may leak secretions such as blood or feces, especially when the surrounding skin is touched; the outer opening of old fistulas may close while the rest of the tunnel remains, causing pain and swelling until the fistula reopens to allow the secretions to escape.
Diagnosis of anal fistula
Diagnosing an anal fistula relies on a combination of tests to determine its exact course and extension. The doctor usually begins with a physical examination, examining the anal area for an abscess or an abnormal channel that indicates the presence of a fistula. In some cases, the external opening may be closed, necessitating additional tests to determine the presence of the internal opening inside the anus. If the examination is too painful for the patient, then local or general anesthesia, and in some cases operating room anesthesia, may be administered to ensure patient comfort and to obtain an accurate assessment and plan for anal fistula treatment.
Advanced Diagnostic Tests
- Endoscopy or proctoscopy: This procedure visualizes the internal canal of the fistula and provides a direct view of the location and extent of the infection.
- Ultrasound: Helps determine the exact depth and dimensions of the fistula, making it easier to plan treatment.
- Magnetic resonance imaging (MRI): Used in complex fistula cases, it provides high-resolution images of the entire course of the fistula and its relationship to surrounding tissues.
- Endoscopic ultrasound: An alternative to MRI, a probe with an illuminated camera is inserted into the anus to obtain detailed images.
- Hydrogen peroxide injection: It is injected into the external opening of the fistula, which helps localize the infection as it reacts with the pus and produces a foam that shows the course of the canal.
- X-ray fistulography: A special dye is injected into the fistula, making its path visible on X-rays.
If Crohn’s disease or ulcerative colitis is suspected, a colonoscopy or sigmoidoscopy to examine the colon and intestines may be recommended.
Determining the course and extension of the fistula is essential in choosing the appropriate treatment plan. The fistula is categorized based on its direction and how it affects the surrounding tissues, which helps the doctor determine the most effective treatment procedure.
What is the difference between an anal fistula and an anal fissure?
Anal fissure and anal fistula are two different conditions that affect the anal area, but both have distinct causes and symptoms.
An anal fissure is a tear in the lining of the anus, often caused by constipation, diarrhea, or Crohn’s disease, that causes severe pain during and after bowel movements with bleeding or itching and swelling. In contrast, an anal fistula is an abnormal tunnel between the anus and the surrounding skin, usually caused by an infection of the anal glands. It is characterized by constant or intermittent pain, pus, swelling, redness, and itching. Infection remains a major concern, and treatments may require medical intervention, such as surgical anal fistula treatment or lateral internal sphincterotomy in cases of anal fissures, along with antibiotics and continuous medical monitoring.
Anal fistula treatment methods
The anal fistula treatment depends on its complexity, as it requires accurate knowledge of the anatomy to ensure that the infection is drained and the fistula is treated without affecting muscle control. There are various surgical and medical methods of anal fistula treatment, where the doctor chooses the most appropriate technique for each case according to the nature of the fistula and its effect on the surrounding muscles. Anal fistulas usually require surgery because they rarely heal if left untreated.
Traditional surgery for anal fistula treatment
Surgery is the most common anal fistula treatment, where the surgeon surgically opens the fistula, hollows it out, and leaves it open to heal from the inside out. Fistula surgery is often performed to treat simple fistulas that do not significantly affect the anal sphincter and is effective in about 95% of cases. This option may only be appropriate for fistulas that do not pass through much of the anal sphincter, to reduce the risk of fecal incontinence.
Laparoscopic anal fistula repair
It involves the use of an instrument called an endoscope, a long, thin tube with a camera at the end that is inserted through the anus to see the fistula clearly. After determining the exact path of the fistula, small instruments inside the scope are used to perform the procedure. In some cases, electrodes or other techniques are used to close the fistula effectively.
This method of anal fistula treatment has some benefits:
- Minimize surgical intervention: It doesn’t require large incisions.
- Less pain after the procedure: This leads to a shorter recovery period.
- Less risk: Less susceptible to infections or complications with traditional surgery.
However, despite its benefits, this technique may only be suitable for some cases and may not work too much for complex fistulas or those that pass through the sphincter muscles.
Seton Threading for anal fistula treatment
When an infection is present, or the fistula is complex and passes through a large percentage of the sphincter muscle, a surgical suture called a seton, a silk or latex thread inserted into the fistula’s path to allow the infection to drain gradually. Sometimes, the seton is slowly tightened over a long period to open the fistula without damaging the muscle, reducing the risk of fecal incontinence. Sometimes, the seton is kept in the fistula for several weeks to help it heal before another surgery to repair the fistula.
Rectal flap for anal fistula treatment
This technique treats a fistula that extends through a large percentage of the sphincter muscle. The surgeon removes the internal opening of the fistula and then covers it with a slice of healthy tissue taken from the rectum. This method helps minimize damage to the anal muscles, but it is only about 70% effective, and there is a risk of recurrent infection in some cases.
LIFT (Ligation of Intersphincteric Fistula Tract) procedure
This technique treats a complex fistula that passes between the sphincter muscles. The surgeon will ligate the center of the fistula’s path at this level to prevent it from continuing. The external opening is drained extensively to ensure the wound heals properly. This method has the advantage of being less risky to the sphincter muscle but less effective than fistulotomy, with a success rate of about 75%. The technique has shown promising results since its recent introduction, but more research is needed to determine its short- and long-term success.
Fibrin Glue for anal fistula treatment
Fibrin glue is a minimally invasive treatment in which the fistula pathway is cleaned and injected into the fistula to close it. This procedure is non-invasive and does not require tissue removal, but it is less effective than surgery, and the fistula may recur after treatment. This option is helpful for fistulas that pass through the anal sphincter muscles because it does not require cutting.
Anal Fistula Plug for anal fistula treatment
This technique inserts a special plug made of biological material into the fistula to close it and promote tissue healing. This method is less invasive than traditional surgery but requires careful monitoring to ensure success.
Laser Fistula Treatment
Laser is one of the latest technologies used in the treatment of anal fistula, in which a laser probe is inserted into the path of the fistula, closing it and promoting tissue healing without the need to remove part of the muscle. Lasers are a suitable option for cases that require a less invasive intervention on the anal muscles but are still being studied and developed.
Medications for anal fistula treatment
In some cases, if the fistula is associated with chronic inflammatory diseases such as Crohn’s disease, it can be healed with drug therapy without surgery. Immunosuppressant medications such as infliximab help reduce inflammation and stimulate fistula healing. However, this treatment is ineffective in all cases and is usually a temporary solution before surgical intervention.
Risks of anal fistula surgery
Although surgery is the most effective anal fistula treatment, it may carry some risks, such as recurrent infections that may require antibiotics or fistula relapse, especially if it does not heal completely. Some patients may suffer from partial fecal incontinence if the sphincter muscles are affected during surgery. It is worth noting that the surgery is usually performed under general anesthesia, and many patients do not require an overnight hospital stay after the operation. Still, some may require a more extended stay. Choosing a surgeon experienced in this field is always best to ensure the best results and minimize complications.
Anal fistula complications, if left untreated
If an anal fistula isn’t treated, it won’t heal on its own, which can lead to long-term complications, including:
- Persistent infection: A fistula caused by an abscess or infection may remain active, allowing the infection to persist in the area. Sometimes, the infection may appear to have disappeared but later return to form a new abscess that causes renewed pain. Sometimes, the fistula may temporarily close at the external opening but reopen due to repeated infections, leading to a continuous cycle of inflammation and drainage.
- Fistula extension: In rare cases, a chronic fistula may develop and extend in new directions, forming branching channels and additional openings in the skin. This further complicates the condition and makes treatment more difficult.
- Risk of cancer: In some less common cases, a chronic anal fistula that persists for many years may be associated with an increased risk of anal cancer. Chronic inflammation and ongoing tissue erosion are thought to be contributing factors.
Due to these aforementioned complications, it is advisable to treat anal fistula in its early stages to avoid all these potential complications.
If you feel any symptoms that indicate the presence of an anal fistula, we advise you to contact the specialists at Bimaristan Medical Center in Turkey. Our team of specialized doctors will provide you with an accurate diagnosis and proper treatment using the latest medical methods. Do not hesitate to book your consultation with us now to get the care you deserve.
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