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Fistula-in-Ano
Author: Juan L Poggio, MD, MS, FACS, FASCRS; Chief Editor: John Geibel, MD, DSc, MA more...
Updated: Sep 9, 2013
Overview
A fistula-in-ano is an abnormal tract or cavity with an external opening in the perianal area that is communicating
with the rectum or anal canal by an identifiable internal opening. Most fistulas are thought to arise as a result of
cryptoglandular infection with resultant perirectal abscess. The abscess represents the acute inflammatory event,
whereas the fistula is representative of the chronic process. Symptoms generally affect quality of life significantly,
and they range from minor discomfort and drainage with resultant hygienic problems to sepsis. The treatment of
fistula-in-ano remains challenging. Surgery is the treatment of option with the goals of draining infection,
eradicating the fistulous tract, and avoiding persistent or recurrent disease while preserving anal sphincter
function.[1, 2]
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 and can extend from the same primary
opening.
References to fistula-in-ano date to antiquity. The fascination with fistula-in-ano for more than 2000 years is
manifested by the numerous papers and books on the subject. Hippocrates, in about 430 BCE, made reference to
surgical therapy for fistulous disease and he was the first person to advocate the use of a seton (from the Latin
seta, a bristle) . In 1376, the English surgeon John Arderne (1307-1390) wrote Treatises of Fistula in Ano;
Haemmorhoids, and Clysters, which described fistulotomy and seton use. Historical references indicate that Louis
XIV was treated for an anal fistula in the 18th century. Salmon established a hospital in London (St. Mark's)
devoted to the treatment of fistula-in-ano and other rectal conditions.[3]
In the late 19th and early 20th centuries, prominent physician/surgeons, such as Goodsall and Miles, Milligan and
Morgan, Thompson, and Lockhart-Mummery, made substantial contributions to the treatment of anal fistula. These
physicians offered theories on pathogenesis and classification systems for fistula-in-ano.[4, 5]
Since this early progress, little has changed in the understanding of the disease process. In 1976, Parks refined
the classification system that is still in widespread use. Over the last 30 years, many authors have presented new
techniques and case series in an effort to minimize recurrence rates and incontinence complications, but despite
2,000 years of experience, fistula-in-ano remains a perplexing surgical disease.
Frequency
The true prevalence of fistula-in-ano is unknown. The incidence of a fistula-in-ano developing from an anal
abscess ranges from 26-38%.[1, 6] One study showed that the prevalence rate of fistula-in-ano is 8.6 cases per
100,000 population. The prevalence in men is 12.3 cases per 100,000 population and in women is 5.6 cases per
100,000 population. The male-to-female ratio is 1.8:1. The mean age of patients is 38.3 years.[7]
Differential diagnoses
The following do not communicate with the anal canal:
Hidradenitis suppurativa
Infected inclusion cysts
Pilonidal disease
Bartholin gland abscess in females
Treatment
Fistula-in-ano is treated surgically. No definitive medical therapy is available for this condition; however, long-term
antibiotic prophylaxis and infliximab may have a role in recurrent fistulas in patients with Crohn disease.
Patient education
For patient education information, see the Digestive Disorders Center, as well as Anal Abscess, Rectal Pain, and
Rectal Bleeding.
Etiology
The vast majority of fistulas-in-ano are nearly always caused by a previous anorectal abscess. There are typically
8-10 anal crypt glands at the level of the dentate line in the anal canal arranged circumferentially. These glands
penetrate the internal sphincter and end in the intersphincteric plane. These glands afford a path for infecting
organisms to reach the intramuscular spaces. The cryptoglandular hypothesis states that an infection begins in the
anal canal glands and progresses into the muscular wall of the anal sphincters to cause an anorectal abscess.
Following surgical or spontaneous drainage in the perianal skin, occasionally a granulation tissuelined 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.[8, 9]
Other fistulas develop secondary to trauma (eg, rectal foreign bodies), Crohn disease, anal fissures, carcinoma,
radiation therapy, actinomycoses, tuberculosis, and lymphogranuloma venereum secondary to chlamydial
infection.
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Relevant Anatomy
A thorough understanding of the pelvic floor and sphincter anatomy is a prerequisite for clearly understanding the
classification system for fistulous disease. (See the image below.)
The external sphincter muscle is a striated muscle under voluntary control by 3 components: submucosal,
superficial, and deep muscle. Its deep segment is continuous with the puborectalis muscle and forms the anorectal
ring, which is palpable upon digital examination.
The internal sphincter muscle is a smooth muscle under autonomic control and is an extension of the circular
muscle of the rectum.
In simple cases, the Goodsall rule can help to anticipate the anatomy of a fistula-in-ano. The rule states that
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. Fistulas with their openings posterior to this line will follow a curved
course to the posterior midline (see image below). Exceptions to this rule are external openings more than 3cm
from the anal verge. These almost always originate as a primary or secondary tract from the posterior midline,
consistent with a previous horseshoe abscess.[10, 11]
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Patient History
Patients often provide a reliable history of previous pain, swelling, and spontaneous or planned surgical drainage
of an anorectal abscess. Signs and symptoms of fistula-in-ano, in order of prevalence, include the following:
Perianal discharge
Pain
Swelling
Bleeding
Diarrhea
Skin excoriation
External opening
Important points in the patients history that may suggest a complex fistula include the following:
Inflammatory bowel disease
Diverticulitis
Previous radiation therapy for prostate or rectal cancer
Tuberculosis
Steroid therapy
Human immunodeficiency virus (HIV) infection
A review of symptoms may reveal the following in patients with a fistula-in-ano:
Abdominal pain
Weight loss
Change in bowel habits
Physical Examination
No specific laboratory studies are required in the diagnosis of fistula-in-ano (although the normal preoperative
studies are performed, based on age and comorbidities). Instead, physical examination findings remain the
mainstay of diagnosis. The examiner should observe the entire perineum, looking for an external opening that
appears as an open sinus or elevation of granulation tissue. Spontaneous discharge of pus or blood via the
external opening may be apparent or expressible on digital rectal examination.
Digital rectal examination may reveal a fibrous tract or cord beneath the skin. It also helps to delineate any further
acute inflammation that is not yet drained. Lateral or posterior induration suggests deep postanal or ischiorectal
extension.
The examiner should determine the relationship between the anorectal ring and the position of the tract before the
patient is relaxed by anesthesia. 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. Proctoscopy is also indicated in the presence of rectal disease, such as Crohn
disease or other associated conditions. Most patients cannot tolerate even gentle probing of the fistula tract in the
office and this should be avoided.
Imaging Studies
Radiologic studies are not performed for routine fistula evaluation since the anatomy of most fistulas-in-ano can be
determined in the operating room. However, they can be helpful when the primary opening is difficult to identify or
for recurrent or persistent disease. In the case of recurrent or multiple fistulas, such studies can be used to identify
secondary tracts or missed primary openings.[13] Several imaging diagnostic modalities are available to evaluate
fistulas-in-ano. The efficacy of each modality is reviewed.
Fistulography
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This technique involves injection of contrast via the internal opening, which is followed by anteroposterior, lateral,
and oblique radiographic images to outline the course of the fistula tract.
Fistulography is relatively well tolerated but it can be painful when injecting the contrast material into the fistulous
tract. It requires the ability to visualize the internal opening. Its accuracy rate has been questioned and it ranges
from 16-48%.[14] .
Due to these limitations, it is generally reserved for cases in which there is a concern about a fistulous connection
between the rectum and adjacent organs such as the bladder, where it may be slightly more useful than a careful
examination under anesthesia.
Endoanal/endorectal ultrasonography
These studies involve passage of a 7- or 10MHz transducer into the anal canal to help define muscular anatomy
differentiating intersphincteric from transsphincteric lesions. A standard water-filled balloon transducer can help to
evaluate the rectal wall for any suprasphincteric extension.
Investigations have shown that the addition of hydrogen peroxide via the external opening can help to outline the
fistula tract course. This may be useful to help delineate missed internal openings.
These studies are reported to be 50% better than physical examination alone to help find an internal opening that
is difficult to localize. This modality has not been used widely for routine clinical fistula evaluation.[15]
MRI
Findings on magnetic resonance imaging (MRI) scans show 80-90% concordance with operative findings when a
primary tract course and secondary extensions are observed. MRI is becoming the study of choice when
evaluating complex fistulas and recurrent fistulas. It has been shown to reduce recurrence rates by providing
information on otherwise unknown extensions.[16, 17]
CT scan
A computed tomography (CT) scan is more helpful in the setting of perirectal inflammatory disease than in the
setting of small fistulas because it is better for delineating fluid pockets that require drainage than for delineating
small fistulas. CT scanning requires administration of oral and rectal contrast. Muscular anatomy is not well
delineated.
Anal Manometry
This modality is rarely used in the evaluation of patients with fistula-in-ano. However, pressure evaluation of the
sphincter mechanism is helpful in certain patients for operative planning, including the following:
Patients in whom decreased tone is observed during preoperative evaluation
Patients with a history of previous fistulotomy
Patients with a history of obstetrical trauma
Patients with a high transsphincteric or suprasphincteric fistula (if known)
Very elderly patients
If a decrease in pressure is found, surgical division of any portion of the sphincter mechanism should be avoided.
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 discomfort or has not helped to 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. They include the following:
Inject hydrogen peroxide, milk, or dilute methylene blue into the external opening and watch for egress at
the dentate line; in the authors' experience, methylene blue often obscures the field more than it helps to
identify the opening
Traction (pulling or pushing) on the external opening may also cause a dimpling or protrusion of the
involved crypt
Insertion of a blunt-tipped crypt probe via the external opening may help to outline the direction of the tract;
if it approaches the dentate line within a few millimeters, a direct extension likely existed (care should be
taken to not use excessive force and create false passages)
Proctosigmoidoscopy/colonoscopy
Rigid sigmoidoscopy can be performed at the initial evaluation to help rule out any associated disease process in
the rectum. Further colonic evaluation is performed only as indicated.
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anorectal sepsis. An abscess develops easily if the external opening on the perianal skin seals itself.
Crohn disease of the perineum with multiple and often complex fistulas requires careful surgical treatment. Acute
perianal abscess requires incision and drainage. Definitive repair of fistulas in these patients requires that the intraabdominal disease be under control with medical therapy. If controlled, routine therapy is warranted. Recurrent
fistulous disease to the rectum and perineum with persistent anorectal sepsis is an indication for
panproctocolectomy. Studies have identified a role in Crohn disease for fistula therapy with infliximab, the
monoclonal antibody to tumor necrosis factor, with 50-60% response rates for perianal fistulas.[18, 19]
Contraindications
If patients are without symptoms and a fistula is found during a routine examination, no therapy is required.
Surgery for fistula-in-ano should not be performed for definitive repair of the fistula in the setting of anorectal
abscess (unless the fistula is superficial and the tract is obvious). In the acute phase, simple incision and drainage
of the abscess are sufficient.[20] Only 7-40% of patients will develop a fistula. Recurrent anal sepsis and fistula
formation are 2-fold higher after an abscess in patients younger than 40 years and are almost 3-fold higher in
nondiabetics.
Intraoperative
Intraoperative considerations include the following:
Examine the patient under anesthesia to confirm the extent of the fistula
Identifying the internal opening to prevent recurrence is imperative
A local anesthetic block at the end of the procedure provides postoperative analgesia
Postoperative
Most patients can be treated in an ambulatory setting with discharge instructions and close follow-up care. Sitz
baths, analgesics, and stool-bulking agents (eg, bran, psyllium products) are used in follow-up care. Frequent
office visits within the first few weeks help to ensure proper healing and wound care.
Importantly, ensure that the internal wound does not close prematurely, causing a recurrent fistula. Digital
examination findings can help to distinguish early fibrosis. Wound healing usually occurs within 6 weeks.
Fistulotomy
The laying-open technique (fistulotomy) is useful for 85-95% of primary fistulas (ie, submucosal, intersphincteric,
low transsphincteric). (See the image below.)[21, 22, 23, 24]
A probe is passed into the tract through the external and internal openings. The overlying skin, subcutaneous
tissue, and internal sphincter muscle are divided with a knife or electrocautery, thereby opening the entire fibrous
tract.
At low levels in the anus, the internal sphincter and subcutaneous external sphincter can be divided at right angles
to the underlying fibers without affecting continence. This is not the case if the fistulotomy is performed anteriorly in
female patients. If the fistula tract courses higher into the sphincter mechanism, seton placement should be
performed. Curettage is performed to remove granulation tissue in the tract base.
Opening the wound out on the perianal skin for 1-2cm adjacent to the external opening with local excision of skin
promotes internal healing before external closure. Some advocate marsupialization of the edges to improve
healing times. Perform a biopsy on any firm, suggestive tissue.
Complete fistulectomy creates larger wounds that take longer to heal and offers no recurrence advantage over
fistulotomy.
Seton Placement
A seton can be placed alone, combined with fistulotomy, or in a staged fashion. This technique is useful in patients
with the following conditions[25, 26, 27] :
Complex fistulas (ie, high transsphincteric, suprasphincteric, extrasphincteric) or multiple fistulas
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Recurrence and incontinence are important factors to consider when using this technique. The success rates for
cutting setons range from 82-100%; however, long-term incontinence rates can exceed 30%.[28, 29, 30]
LIFT Procedure
Ligation of the intersphincteric fistula tract (LIFT) is a sphincter-sparing procedure for complex transsphincteric
fistulas first described in 2007. It is performed through access to the intersphincteric plane with the goal of
performing a secure closure of the internal opening and by removing the infected cryptoglandular tissue.[42]
The intersphincteric tract is identified and isolated by meticulous dissection done through the intersphincteric plane
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after making a small incision overlying the probe connecting the external and internal openings. Once isolated, the
intersphincteric tract is hooked using a small, right-angled clamp and the tract is ligated close to the internal
sphincter and then divided distal to the point of ligation. Hydrogen peroxide is injected through the external
opening to confirm the division of the correct tract. The external opening and the remnant fistulous tract are
curetted to the level of the proximity of the external sphincter complex. Finally, the intersphincteric incision is
loosely reapproximated with an absorbable suture. The curettaged wound is left opened for dressing.[42, 43, 44]
Research studies on the technique are scarce owing to the novelty of the technique. It compares similarly with the
success rate of the anorectal advancement flap technique in a randomized trial of 39 patients with complex fistulain-ano who had failed previous procedures and were treated by the LIFT technique. The probability of recurrence
at 19 months was 8% versus 7% for those patients treated with anorectal advancement flap. However, the first
group had a shorter time to return to work (1 vs 2 wk), but there was no difference in incontinence scores.[45]
Further randomized surgical trials are needed to determine whether this technique is a viable alternative or better
alternative to the other previously mentioned procedures for the treatment of fistula-in-ano.
Diversion
The creation of a diverting stoma is a rare indication to facilitate the treatment of complex persistent fistulas-in-ano.
The most common indications include but are not limited to patients with perineal necrotizing fasciitis, severe
anorectal Crohn disease, reoperative rectovaginal fistulas, and radiation-induced fistulas. While fecal diversion
alone is effective in these select patients to control sepsis and symptoms, long-term success following
reanastomosis is low because of recurrence from the underlying disease and should be avoided unless the
underlying fistula-in-ano disease process is repaired or has healed completely, which is unlikely.
Prognosis
The postsurgical prognosis in fistula-in-ano is as follows:
Standard fistulotomy - The reported rate of recurrence is 0-18%, and the rate of any stool incontinence is 37%.
Seton use - The reported rate of recurrence is 0-17%, and the rate of any incontinence of stool is 0-17%.
Mucosal advancement flap - The reported rate of recurrence is 1-17%, and the rate of any incontinence of
stool is 6-8%[31]
Postoperative complications
Early postoperative complications may include the following:
Urinary retention
Bleeding
Fecal impaction
Thrombosed hemorrhoids
Delayed postoperative complications may include the following:
Recurrence
Incontinence (stool)
Anal stenosis - The healing process causes fibrosis of the anal canal; bulking agents for stool help to
prevent narrowing
Delayed wound healing - Complete healing occurs by 12 weeks unless an underlying disease process is
present (ie, recurrence, Crohn disease)
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