Anal Fistula - Symptoms, Causes, Prevention, Treatment
Fistula in Ano, also known as anal fistula, is an abnormal passage or tunnel that connects the anus or rectum to the skin around the anal region. This condition typically stems from an infection in the anal glands, leading to the formation of an abscess that, if left untreated, can progress into a fistula. The fistulous tunnel typically has two openings: an internal opening towards the anal canal and an external opening on the skin. Simple fistulas, often resulting from glandular obstruction, are characterized by a single tract and are relatively straightforward to diagnose and treat. Surgical intervention is commonly required for the resolution of simple fistulas, which generally exhibit a lower recurrence rate and fewer complications. On the other hand, complex fistulas pose greater challenges as they involve multiple tracts and are frequently associated with underlying conditions such as Crohn’s disease or rectal inflammatory diseases. Diagnosing and treating fistulas is crucial to alleviate symptoms, prevent complications, and enhance overall well-being. Symptoms may include pain during bowel movements, drainage of pus or blood, swelling, fever, and recurrent abscess formation. Diagnosis involves clinical examination and, in some cases, imaging studies. Surgical procedures aim to remove the abnormal tract, and antibiotic therapy may be employed in cases of infection. Early medical intervention is essential to manage fistulas effectively and improve patient outcomes.
Symptoms of Fistula in Ano:
Pain and Discomfort: Individuals with anal fistulas often experience pain and discomfort, especially during bowel movements.
Drainage of Pus or Blood: Pus or blood may drain from the external opening of the fistula, and this drainage may cause irritation and staining of undergarments.
Swelling and Redness: The skin around the anal opening may become swollen and red due to inflammation associated with the fistula.
Fever and Malaise: In cases of infection, individuals may develop a fever along with a general feeling of illness (malaise).
Recurrent Abscess Formation: Fistulas are often preceded by the formation of abscesses in the anal region. Recurrent abscesses may be an indicator of an underlying fistula.
Itching and Irritation: The presence of drainage and inflammation can lead to itching and irritation in the anal area.
Diagnosis and Treatment:
Clinical Examination: A healthcare provider, often a proctologist, can diagnose a fistula through a physical examination of the anal area. The external and internal openings of the fistula are typically identified during this examination.
Imaging Studies: In some cases, imaging studies such as an MRI or fistulography may be recommended to assess the structure and extent of the fistula, especially in complex cases.
Surgical Treatment: Surgical intervention is the primary treatment for fistula in ano. The goal is to remove the abnormal tract and promote healing. The type of surgical procedure depends on the complexity and location of the fistula.
Antibiotics: In cases of infection, antibiotics may be prescribed to control the spread of infection and promote healing.
What is Anal Fistula?
Anal fistula, medically referred to as Fistula in Ano, is an abnormal passage or tunnel that forms between the anal canal and the skin near the buttocks. The anus serves as the exit point for the expulsion of feces from the body. This fistulous tunnel typically features two openings: an internal opening directed towards the anal canal and an external opening on the skin surface.
The development of an anal fistula is commonly associated with infection and the accumulation of pus in the anal glands. These glands, responsible for secreting fluids that aid in the lubrication of the anal canal, can become infected, leading to the formation of an abscess. If this abscess does not properly drain and heal, it can evolve into a fistula.
It’s noteworthy that anal fistulas are distinct from other anorectal conditions, such as piles or hemorrhoids, yet they are occasionally confused due to shared symptoms. Anal fistulas can cause pain, drainage of pus or blood, and swelling in the anal region. Proper diagnosis by a healthcare professional is crucial for accurate differentiation and effective treatment.
Management of anal fistulas typically involves surgical intervention to remove the abnormal tract, promoting healing and preventing recurrence. Early diagnosis and appropriate medical attention are essential for addressing anal fistulas and minimizing potential complications associated with this condition.
Fistulas may be simple or complex in structure.
- Simple Fistula-
A simple fistula, also known as a low anal fistula, is a type of abnormal passage or tunnel that forms between the anal canal and the skin around the anus. Here is more detailed information about simple fistulas:
Characteristics:
Glandular Obstruction: Simple fistulas typically originate from glandular obstruction in the anal canal. This obstruction leads to the development of an abscess, which, if left untreated, can progress to form a fistula.
Single Tract: One defining characteristic of a simple fistula is that it consists of a single tract or tunnel. This means that the abnormal passage has one internal opening toward the anal canal and one external opening on the skin surface.
Diagnosis:
Clinical Examination: Diagnosis of a simple fistula usually involves a clinical examination by a healthcare professional, such as a proctologist or colorectal surgeon. The external and internal openings of the fistula are identified during this examination.
Imaging Studies (if needed): In some cases, additional imaging studies such as an MRI or fistulography may be recommended to assess the structure and extent of the fistula.
Treatment:
Surgical Intervention: The primary treatment for a simple fistula is surgical intervention. The goal of the surgery is to remove the abnormal tract, allowing for proper drainage and promoting healing.
Low Recurrence Rate: Simple fistulas generally have a low recurrence rate, meaning that the chances of the fistula returning after surgical treatment are relatively minimal.
Fewer Complications: Compared to complex fistulas, simple fistulas are associated with fewer complications. The straightforward nature of their structure makes them more amenable to successful surgical management.
Recovery:
Postoperative Care: After surgical treatment, patients are typically provided with postoperative care instructions, which may include measures to promote proper healing and reduce the risk of infection.
Follow-up: Regular follow-up appointments with the healthcare provider are important to monitor the healing process and address any concerns or complications that may arise.
Understanding the characteristics and treatment options for simple fistulas is crucial for both patients and healthcare professionals. Early diagnosis and appropriate surgical intervention contribute to successful outcomes and a lower likelihood of recurrence.
- Complex Fistula-
A complex fistula, also known as a high anal fistula, is a more intricate and challenging form of an abnormal passage or tunnel that forms between the anal canal and the surrounding skin. Here is more detailed information about complex fistulas:
Characteristics:
1. Recurrent Fistulas: Complex fistulas are characterized by their recurrence, meaning that individuals may experience multiple fistulas or the reappearance of a fistula after previous treatments.
2. Multiple Tracts: Unlike simple fistulas, complex fistulas involve multiple tracts or tunnels. These additional pathways make the fistula more intricate and difficult to treat.
3. Associated with Underlying Diseases: Complex fistulas are often associated with underlying medical conditions. Common associations include Crohn’s disease, inflammatory disease of the rectum, or a history of radiation therapy.
Diagnosis:
1. Clinical Examination: Diagnosis involves a thorough clinical examination by a healthcare professional, usually a proctologist or colorectal surgeon. This examination aims to identify the internal and external openings of the fistula, as well as assess its complexity.
2. Imaging Studies: Additional imaging studies such as MRI or fistulography may be essential to provide a detailed understanding of the fistula’s structure, location, and involvement of surrounding tissues.
Treatment:
1. Multidisciplinary Approach: Managing complex fistulas often requires a multidisciplinary approach involving various specialists, including colorectal surgeons, gastroenterologists, and sometimes radiologists.
2. Addressing Underlying Conditions: Treatment strategies for complex fistulas may involve addressing and managing the underlying conditions, such as inflammatory bowel disease or radiation-induced damage.
3. Surgical Intervention: Surgical treatment is typically required, but the approach may be more complex. Procedures may include the use of advanced techniques, seton placement, or more extensive surgeries to address multiple tracts.
Challenges:
1. Higher Recurrence Rates: Complex fistulas generally have higher recurrence rates compared to simple fistulas, requiring careful monitoring and possibly additional interventions over time.
2. Complications: Due to their complexity and association with underlying conditions, complex fistulas may be associated with more complications than simple fistulas.
Understanding the characteristics and challenges associated with complex fistulas is crucial for healthcare professionals in developing an appropriate treatment plan. The multidisciplinary approach and consideration of underlying conditions are key factors in managing the complexities of this type of anal fistula effectively.
Anal Fistula Cause
An anal fistula is generally caused by blocking the anal glands, which builds up the bacterial infection forming an inflamed pocket of infected tissues and liquids that result in an anal abscess which finds its way out through the skin(surgically drained and spontaneous rupture).
Uncommonly It also develops from other conditions:-(Complex Fistula)
Ulcerative colitis and Crohn’s disease
- Tuberculosis
- Sexually transmitted disease
- Trauma
- Anorectal cancer
Symptoms of Anal Fistula
Symptoms of Anal Fistula
The symptoms are not limited to these, and these usually follow a repetitive cycle,
The most common symptoms of fistula in ano are –
- Painful bowel movement and urination.
- Itching and irritated skin in the perianal region
- One might be able to feel the external opening around the anus.
- Frequent anal abscesses.
If the fistula is associated with an abscess, you may experience:
- throbbing pain in the rectal area due to the formation of an abscess
- Swelling and redness around the anus suggest a collection of pus and the formation of an abscess
- Fever
- Repetitive cyclical foul smell discharge once every 4 to 8 weeks.
- Bleeding from anus
- Discharge pus from anus
Diagnosis of Anal FIstula
Diagnosis
- Physical examination:
Inspection of the skin surface near the anal area will be done by the doctor to check tenderness and pus discharge after reviewing the patient’s medical history and symptoms.
2. Rectal Examination:
The doctor may insert his finger in the anus(using lubricant and wearing gloves) to locate the fistula opening and look for signs such as oozing fluid or bleeding.
3 . Proctoscopy- The fistula probe is attached to a specialized telescope with a light on one end to see inside the rectum and visualize the fistula.
4.Investigations:
- Other diagnostic tests performed to locate the exact fistula tract:
- Anal Endosonography- Ultrasound images of the pelvic floor area help to determine the location of the fistula tract.
- Fistulography- A contrast dye is injected into the fistula tract and X-rays are taken to visualize the path of the tract.
- MRI( Magnetic Resonance Imaging)- It is considered the gold standard in the diagnosis of anal fistulas. MRI scans can even define complex and recurring fistulas due to high soft tissue resolution.
Treatment for anal Fistula
Treatment
Anal fistula does not heal completely on its own, surgery is necessary to treat it. A fistula associated with Crohn’s disease can be attempted to treat with medications as surgical success rates are low.
The main aim of surgery is to get rid of the fistula while protecting the anal sphincter muscles(a ring of muscles that controls opening and closing of the anus) which might cause bowel incontinence(loss of bowel control) if damaged.
Home remedies for acute pain relief:
- Some self-care measures may help to relieve pain and discomfort:
- Sitz bath.
- Eat healthily and take more fibrous food, include honey, oregano oil, flax seeds in your diet and apply coconut oil to the anal sphincter.
- Drink plenty of water and fruit juices.
- Avoid alcohol.
- Add ginger tea and turmeric milk to your daily diet. This will help in preventing constipation.
- An excess amount of water makes stool soften and also helps to clean the intestine. OTC Stool Softeners might also be useful in the acute stage.
Medications- Painkillers can be taken over the counter on the doctor’s advice.
Ayurvedic management:
- Abhyangam
- An ayurvedic massage with special oils and in specific directions relieves pain.
- Avagaha Sweda
- After an oil massage, sitting in neck-deep warm water infused with ayurvedic herbs. It aids in rejuvenation and relieves pain.
- Dhumpana
- A medicinal smoke therapy that relieves pain caused due to anal fistula
- Kshara Sutra
- It is a seton thread medicated with ayurvedic medicine inserted into the fistula tract which acts as an antiseptic and aids in the healing of the fistula. The mechanical action of thread and the therapeutic action of the medicine coated on the thread act collectively to promote healing.
- Other Ayurvedic herbs such as Triphala, Guggulu, Haridra, Jatyadi Ghrita are used for symptomatic treatment.
Surgical Management
Surgery is considered the gold standard treatment for fistula as it results in a permanent cure. Several surgical techniques are available depending upon the location and severity of the fistula( simple or complex).
These are some surgical techniques:
- Fistulotomy: This is the most common and effective treatment for patients with simple fistulas. In this procedure, the surgeon cuts off the whole length of the fistula so it can heal as a plain scar. It is generally an outpatient procedure. You can go home the same day.
- Seton techniques: In this procedure, the surgeon tightened the fistula with the help of a suture or rubber band. It heals the fistula behind the seton and also lowers the risk of incontinence. Recommended for long, complex and high fistulas.
- Laser surgery: In this procedure, a small laser fibre is inserted into the track and the laser seals the tract with heat and coagulation.
- Advancement Flap procedure
In this procedure, the fistula is scraped and then the internal opening of the track is closed with a piece of tissue or skin called the advancement flap( taken from the rectum or anus).
This is used to treat fistulas passing through the sphincter muscles to avoid intontinence. It has a lesser success rate than fistulotomy.
5. LIFT-ligation of the intersphincteric fistula tract
- It is a new technique for fistulas associated with anal sphincter muscles. Here the skin above the fistula is opened, the sphincter muscles are pushed apart and the internal opening of the fistula is ligated (tied off)with a suture. The infected tract is then removed and the wound is cleaned and scraped thoroughly. This procedure can be used as a second stage for the seton technique.
Non-Surgical Management
Fibrin Glue method
- In this technique, the internal and external openings of the fistula tract are identified and cleaned thoroughly. A Special glue made from a fibrous protein (fibrin) is then injected into the tract which seals the fistula and aids in healing.
Benefits of Treatment
Anal Fistula treatment helps in
1) Respite from the bad odour discharge from the anal region , which is quite embarrasing
Risk and delay in treatment for anal fistula
- Recurrence of fistula
- Anaemia
- Unbearable Anal Pain
- Development of multiple anla fissures
- Extension of anal Fissures
- Anal Stenosis
- Fecal incontinence
- Strangulation
