Anal Fistula2

Anatomy Recall
Illustration
Anal Disorders
Fistula-in-Ano
Background
A fistula-in-ano is a hollow tract lined
with granulation tissue connecting:
a primary opening inside
the anal canal to
a secondary opening in the
perianal skin
Secondary tracts may be multiple

Anal Disorders
Fistula-in-Ano
Background
A symptomatic fistula-in-ano
requires surgery, because
spontaneous healing is very rare
The objective of fistula surgery is to

cure the fistula:
with the lowest possible
recurrence rate and
with minimal, if any, change in
Anal Disorders
Fistula-in-Ano
Background
To accomplish this, the surgeon must understand
the ramifications of fistulous tracts
The classification system described by Parks and

colleagues serve as a guide to surgical treatment
Anal Disorders
Fistula-in-Ano
Background
Frequency:
The prevalence rate is 8.6 cases per 100,000
population
The prevalence:
In men is 12.3 cases per 100,000 population
In women, it is 5.6 cases per 100,000
population
Anal Disorders
Fistula-in-Ano
Background
Etiology
Fistula-in-ano is nearly always caused by a
previous anorectal abscess
Anal canal glands situated at the dentate line

afford a path for infecting organisms to
reach the intramuscular spaces
Anal Disorders
Fistula-in-Ano
Background
Etiology
Other fistulae develop secondary to:
trauma Crohn disease
anal fissures carcinoma
radiation therapy actinomycoses
tuberculosis and
chlamydial infections
Anal Disorders
Fistula-in-Ano
Background
Pathophysiology
The cryptoglandular hypothesis states that:
(1) an infection begins in the anal gland
and
(2) progresses into the muscular wall of
the anal sphincters to cause (3) an
anorectal abscess
Anal Disorders
Fistula-in-Ano
Background
Pathophysiology
Following surgical or spontaneous drainage
in the perianal skin, occasionally a
“granulation tissue–lined tract” is left
behind, causing recurrent symptoms
Multiple series have shown that the

formation of a fistula tract following
anorectal abscess occurs in 7- 40% of
cases
Anal Disorders
Fistula-in-Ano
Clinical
History
Signs and symptoms; in order of
prevalence
1) Perianal discharge 2) Pain 3) Swelling
4) Bleeding 5) Diarrhea
6) Skin excoriation 7) External opening
Fistula-in-Ano
Clinical
Past medical history
* Inflammatory bowel disease
* Diverticulitis
* Previous radiation therapy for:
prostate or
rectal cancer
* Tuberculosis
* Steroid therapy
* HIV infection
Anal Disorders
Fistula-in-Ano
Clinical
Review of symptoms
Abdominal pain
Weight loss
Change in bowel habits
Anal Disorders
Fistula-in-Ano
Clinical
Physical examination
Physical examination findings remain the mainstay of
diagnosis
Anal Disorders
Fistula-in-Ano
Clinical
The examiner should observe the entire perineum,
looking for an external opening that appears as:
an open sinus or
elevation of granulation tissue
Anal Disorders
Fistula-in-Ano
Clinical
Spontaneous discharge via the external
opening may be:
apparent or
expressible upon digital rectal
examination
Anal Disorders
Fistula-in-Ano
Clinical
Digital rectal examination may reveal:
a fibrous tract cord beneath the skin or
acute inflammation that is not yet
drained
Anal Disorders
Fistula-in-Ano
Clinical
The examiner should determine the
relationship between the anorectal ring
and the position of the tract before
the patient is relaxed by
anesthesia
Anal Disorders
Fistula-in-Ano
Clinical
The sphincter tone and voluntary
squeeze pressures should be assessed
before any surgical intervention to
delineate whether preoperative
manometry is indicated
Anoscopy is usually required to

identify the internal opening
Anal Disorders
Fistula-in-Ano
Clinical
Differential diagnoses
The following do not communicate with
the anal canal:
Hidradenitis suppurativa
Infected inclusion cysts
Pilonidal disease
Bartholin gland abscess in females
Anal Disorders
Fistula-in-Ano
Indications
Therapeutic intervention is indicated
for symptomatic patients
If patients are without symptoms and a

fistula is found during a routine
examination, no therapy is required
Anal Disorders
Fistula-in-Ano
Parks Classification System
The Parks classification system defines
4 types of fistula-in-ano that result
from cryptoglandular infections
Intersphincteric
Common course - Via internal sphincter to
the intersphincteric space and then to the
perineum Simple intersphincteric fistula
* 70% of all anal fistulae
• Parks Classification System (Fistula-in-Ano)
• Intersphincteric
Other possible tracts
a)Intersphincteric fistula with a high blind tract
b) Intersphincteric fistula with high tract opening into

the lower rectum
c) High intersphincteric without a perineal opening
d) Intersphincteric fistula from pelvic disease

Fistula-in-Ano
Transsphincteric
Common course - Low via internal and
external sphincters into the ischiorectal fossa
and then to the perineum
25% of all anal fistulae
Other possible tracts:
* High tract with perineal opening
* high blind tract
Fistula-in-Ano
Suprasphincteric
Common course - Via intersphincteric space
superiorly to above puborectalis muscle into
ischiorectal fossa and then to perineum
5% of all anal fistulae
Anal Disorders
Fistula-in-Ano
Background
Extrasphincteric
Common course The tract begins at
the rectum or sigmoid colon and
extend downward, passes through the
levator ani muscle and then to
perineum around the anus
1% percent of all anal fistulae
Anal Disorders
Fistula-in-Ano
Contraindications:
Surgery for fistula-in-ano should not be
performed for definitive repair of the
fistula in the setting of anorectal abscess
i.e. unless the fistula is superficial and
the tract is obvious)
Anal Disorders
Fistula-in-Ano
Workup
Lab studies
No specific laboratory studies are
required
The normal preoperative studies are

performed based on:
age and
comorbidities
Anal Disorders
Fistula-in-Ano
Imaging Studies
Radiologic studies: These are not
performed for routine fistula evaluation
They can be helpful when

1) the primary opening is difficult to identify
or in the case of 2) recurrent
or 3) multiple fistulae to identify secondary

tracts or missed primary openings
Anal Disorders
Fistula-in-Ano
Background
Imaging Studies
Fistulography
This involves injection of contrast via
the internal opening, which is
followed by x-ray images to outline
the course of the fistula tract
Imaging Studies
Endoanal/endorectal ultrasound
These studies help to define muscular anatomy
differentiating:
* intersphincteric from
* transsphincteric lesions
CT scan
A CT scan is more helpful:
* in the setting of perirectal inflammatory
disease than
* in the setting of small fistulae
Anal Disorders
Fistula-in-Ano
Background
Imaging Studies
MRI
Is becoming the study of choice when
evaluating complex fistulae
It has been shown to improve recurrence

rates by providing information on
otherwise unknown extensions
Anal Disorders
Fistula-in-Ano
Background
Imaging Studies
A barium enema
This is useful for patients with:
multiple fistulae or
recurrent disease
to help rule out IBD
Other Tests
Anal manometry
Pressure evaluation of the sphincter
mechanism is helpful in certain
patients
1) Decreased tone observed during
preoperative evaluation
2) History of previous fistulotomy
3) History of obstetrical trauma
4) High transsphincteric or
suprasphincteric fistula (if known)
5) Very elderly patients
Anal Disorders
Fistula-in-Ano
Diagnostic Procedures
Examination under anesthesia
An examination of the perineum:
* digital rectal
examination and
* anoscopy
are performed after the anesthesia of
choice is administered
This examination is necessary before
surgical intervention, especially if
outpatient evaluation causes:
1) discomfort or
2) has not helped delineate the
course of the fistulous process
Several techniques have been

described to help locate the course of
the fistula and, more importantly,
identify the internal opening
Anal Disorders
Fistula-in-Ano
Inject hydrogen peroxide
milk or
dilute methylene blue
into the external opening and watch
for egress at the dentate line
Anal Disorders
Fistula-in-Ano
Insertion of a blunt-tipped crypt
probe via the external opening may
help outline the direction of the tract
Anal Disorders
Fistula-in-Ano
* Proctosigmoidoscopy
* Colonoscopy
* Rigid sigmoidoscopy
can be performed at the initial evaluation to
help rule out any associated disease
process in the rectum
Anal Disorders
Fistula-in-Ano
Treatment
Medical therapy
No definitive medical therapy is available
Anal Disorders
Fistula-in-Ano
Treatment
Surgical therapy
Fistulotomy/fistulectomy/seton
THANKS

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Anatomy Recall

Secondary tracts may be multiple

The objective of fistula surgery is to

The classification system described by Parks and

Anal canal glands situated at the dentate line

Multiple series have shown that the

Anoscopy is usually required to

If patients are without symptoms and a

b) Intersphincteric fistula with high tract opening into

c) High intersphincteric without a perineal opening

d) Intersphincteric fistula from pelvic disease

The normal preoperative studies are

They can be helpful when

or in the case of 2) recurrent

or 3) multiple fistulae to identify secondary

It has been shown to improve recurrence

Several techniques have been

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