Session 5-Anorectal Fistula

CMT 06207 Apprenticeship in Surgery
Session 6 Anorectal fistula

Learning objectives
At the end of this session, students are expected to be
able to:
• Define Anorectal fistula
• Describe causes and clinical presentation Anorectal
fistula
• Class anorectal fistula
• Identify differential diagnosis Anorectal fistula
• Describe management of Anorectal fistula
Activity: Brainstorming
• What is anorectal fistula?

Definition of Anorectal fistula (fistula-in-ano)
• Is a connection between the anorectal canal and perianal area.
OR
• Is an abnormal hollow tract or cavity that is lined with granulation
tissue(vascularized tissue formed during healing process from

infection or foreign body) and that connects a primary opening inside
the anal canal to a secondary opening in the perianal skin;
• It usually occurs in a pre-existing anorectal infection or

abscess which burst spontaneously.
Causes of Anorectal fistula
The cause of Anorectal fistula (fistula-in-ano) can be;
• Cryptoglandular—90%. i.e infection of glands in anal canal
• Non-cryptoglandular (other causes)—10%.
Anatomy of anal glands (Cryptoglands of
Morgagni).
Cryptoglandular cause
• It is the infection of the intersphincteric
glands that initiates the fistula-in-ano,
known as the “cryptoglandular
hypothesis”
o These glands present in the
subepithelium and internal sphincter
o These glands secrete mucus to
lubricate anus
• Infection in the intersphincteric gland

result in formation of abscess and later
fistula.
Non-cryptoglandular cause
The following are the other cause of anorectal fistula;
• Tuberculosis
• Carcinoma;
oColloid carcinoma of rectum(tissues changed and another form and start producing mucus)
can present as multiple fistulae in ano.
• Crohn’s disease, Ulcerative colitis (inflammatory bowel diseases)
• Lymphogranuloma venereum(an ulcerative disease of the genital area caused by the gram-
negative bacteria Chlamydia trachomatis)
• Hidradenitis suppurativa(a painful, long-term skin condition that causes abscesses and scarring
on the skin in armpits, groin, bottom, breasts )
• Traumatic
Classification of Fistula
Classification of fistula-in-ano according to;
• Standard (Milligan Morgan, 1934; Goligher 1975)
• Park`s classification (1976)
Standard (Milligan Morgan, 1934;
Goligher 1975) of anal fistula
Fistula-in ano is
classified as
• 1. Subcutaneous
• 2. Submucous
• 3. Low anal
• 4. High anal
• 5. Pelvirectal
Park`s classification
There are four types of Parks classification
• Type 1: Intersphincteric:
• Type 2: Trans-sphincteric
• Type 3: Suprasphincteric
• Type 4: Extrasphincteric
Park`s classification cont….
Type 1: Intersphincteric
• The fistula is confined to the
intersphincteric plane.
• It is the commonest fistula
accounting 45%
Type 2: Trans-sphincteric
• The fistula traverses the
external sphincter,
communicating with the
ischiorectal fossa.
• It accounts for 30% of
fistula-in- ano.
Type 3: Suprasphincteric:
• The fistula extends cephalad
over the external sphincter
and perforates the levator
ani.
• It accounts for 20% of
fistula-in ano.
Type 4: Extrasphincteric:
• The fistula extends from the
rectum to the perianal skin,
external to the sphincter
apparatus.
• It accounts for 5% of fistula-in
ano.
• What are clinical presentation of fistula-in-ano?
Clinical presentation of Fistula-in-ano
• It presents with seropurulent discharge (65%)
• Along with skin irritation
• One or more external opening may be present with induration
of the surrounding skin.
• External opening can be single/multiple
Clinical presentation of Fistula-in-ano
• Internal opening in carcinoma felt as a 'button hole' defect ( an

isolated tear of the anal epithelium or rectal mucosa and vagina but without involving the anal
sphincter) inside the rectum.
• Previous history of anal gland infection, with recurrent

abscess.
• Often it may heal superficially but pus may collect beneath
forming an abscess which again discharges through same or
new opening.
Goodsall’s Rule
• Goodsall's rule: Fistulas
with an external opening anterior to a
plane passing transversely through the
center of the anus will follow a straight
radial course to the dentate line
provided it less than 3 cm from the anal
verge Fistulas with their openings
posterior to this line will follow a
curved course to the posterior midline
• The internal opening is

marked A and external
opening B
Goodsalles’ rule cont….
• Figure 1 shows anterior fistula
in-ano (single)
• Figure 2 shows fistula in ano

both anterior and posterior
(Multiple).
• What are differential diagnosis of fistula-in-ano?
Differential diagnosis for fistula-in-ano
The following are differential diagnosis of fistula-in-ano;
• Urethral fistula in male
• Chronically infected Bartholin’s gland( located on each side of the vaginal
opening)
• Pilonidal sinus(An abnormal skin growth located at the tailbone(above buttocks)

that contains hair and skin)
• Hidradenitis suppurativa(usually around groin and buttocks)

• Carcinoma
• Crohn’s tuberculosis, ulcerative colitis
Investigations
The following are investigation that may be ordered;
• Full blood picture
• Pus for ZN-stain rule out Crohn’s tuberculosis
• Swab for culture and sensitivity.
• Chest X-ray
• ESR
• Barium enema X‑ray(detect changes or abnormalities in the large intestine
(colon))
• If required fistulogram is done only under anaesthesia.

Investigations cont…..
• MRI/MRI fistulogram ideal
• Endorectal ultrasound (US perineum) is useful to assess
deeper plane.
• Discharge study, methylene blue dye study
• Colonoscopy often when ulcerative colitis/Crohn’s is
suspected.
• Biopsy for histological studies.
Treatment
• Adequate and appropriate treatment is dependent on correct
classification of the fistula and identification of the internal
and external openings, the course of the track, and the
amount of sphincter muscle involved.
• Surgical treatment remains the primary modality of treatment

for noninflammatory bowel disease–related fistulas.
• Treat the underlying cause to prevent recurrence.

Treatment cont…
• Requires staged procedure-initial colostomy( creates an opening for the
colon, or large intestine, through the abdomen bypassing anal opening) is done followed
by definitive procedure.
oThis prevents sepsis and promotes faster healing.
• Later closure of colostomy is done.
• Refer the patient to a center with expert.

Surgical options for fistula-in-ano
• Fistulectomy
• Fistulotomy
NB: A fistulectomy involves complete excision of the fistulous tract,
thereby eliminating the risk of missing secondary tracts and providing
complete tissue for histopathological examination. A fistulotomy lays
open the fistulous tract, thus leaving smaller unepithelized wounds,
which hastens the wound healing
• Advancement flaps(the flap is used to cover the internal opening of the abnormal
channel and prevent ongoing communication between the anus and the fistula tract)
• Gluing of the fistula(fibrin glue is injected through the opening of the fistula and the
opening is closed with stitches. )
• Anal fistula plug (AFP) repair:

• VAAFT procedure (Video assisted

anal fistula track ligation)
• LIFT technique (Ligation of
intersphincteric fistula track)
• Fistula clip closure (used to repair a hole or
opening (fistula) with the help of an endoscope with fistula
clamp)
• Seton Technique (This allows it to drain and helps

it heal, while avoiding the need to cut the sphincter muscles.
Loose setons allow fistulas to drain, but do not cure them)
Key points
• Anorectal fistula is a track lined by granulation tissue which
connects perianal skin superficially to anal canal; anorectum
or rectum deeply.
• Causes of anorectal fistula are either Cryptoglandular or Non-
cryptoglandular
• It can be classified according to Standard (Milligan Morgan,
1934; Goligher 1975) or Park`s classification
Evaluation
• Define anorectal fistula?
• Classify fistula-in ano according to Park`s
• State Goodsall’s Rule.
• Mention four (4) investigations of anorectal fistula.

Reference
• Courteney M.Townsend, B.Mark Evers, R.D.Beauchamp,
Kenneth L. Mattox (2012) Sabiston textbook of surgery (20 th
edition). Elsevier
• Siram Bhat M (2015) SRB’s Manual of surgery( 5 th edition).

Prakash Rao Thangam venghese Joshua.
• K.Rajgopal Shenoy, Anitha shenoy (2016) Manipal Manual

of surgery (4th edition). CBS New Delhi.

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CMT 06207 Apprenticeship in Surgery

Session 6 Anorectal fistula

• What is anorectal fistula?

tissue(vascularized tissue formed during healing process from

• It usually occurs in a pre-existing anorectal infection or

• Infection in the intersphincteric gland

• Internal opening in carcinoma felt as a 'button hole' defect ( an

• Previous history of anal gland infection, with recurrent

• The internal opening is

• Figure 2 shows fistula in ano

• Pilonidal sinus(An abnormal skin growth located at the tailbone(above buttocks)

• Hidradenitis suppurativa(usually around groin and buttocks)

• If required fistulogram is done only under anaesthesia.

• Surgical treatment remains the primary modality of treatment

• Treat the underlying cause to prevent recurrence.

• Later closure of colostomy is done.

• Refer the patient to a center with expert.

• Anal fistula plug (AFP) repair:

• VAAFT procedure (Video assisted

• Seton Technique (This allows it to drain and helps

• Classify fistula-in ano according to Park`s

• State Goodsall’s Rule.

• Mention four (4) investigations of anorectal fistula.

• Siram Bhat M (2015) SRB’s Manual of surgery( 5 th edition).

• K.Rajgopal Shenoy, Anitha shenoy (2016) Manipal Manual

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