Fistula-in-Ano

A chronic abnormal communication which runs outwards from the

anorectal lumen (the internal opening) to an external opening on the
skin of the perineum or buttock or vagina (women, rare). (Schwartz)
Abnormal hollow tract or cavity that is lined with granulation tissue
and that connects 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.(Medscape)
Must be differentiated from the ff.processes, which do not
communicate with the anal canal:
Hidradenitis suppurativa
Infected inclusion cysts
Pilonidal disease
Bartholin gland abscess in females

Etiology
Majority: caused by previous anorectal abscess
Drainage of anorectal abscess -> results 50% cure
Remaining 50% -> persistent fistula-in-ano
Typically, there are 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. They provide a path by which infecting
organisms can reach the intramuscular spaces.
Infected crypts (internal opening) and tracks to the external opening,
usually the site of the prior drainage.
Course: predicted by the anatomy of the previous abscess
Cryptoglandular in origin (majority)

May be found in specific conditions like:

Trauma (eg. Rectal Foreign bodies)
Crohns disease
Malignancy
Radiation
Infections (tuberculosis, actinomycosis, and chlamydia)
Lymphogranuloma venereum
Rectal duplications
*raise suspicion of diagnoses in a complex, recurrent, or nonhealing
fistula.
Epidemiology (source:Medscape)
True prevalence: unknown
Incidence from anal abscess: 26-38%

Diagnosis
Persistent drainage - external and internal
Indurated - palpable
Goodsalls rule - guide in determining location

Goodsalls rule

Used to indicate the likely position of the interior opening

according to position of the exterior opening (helpful but not
infallible).
Probing in an awake patient is painful, unhelpful, and
dangerous.

EO anterior -> connect to IO by a short, radical tract

EO posterior -> track in a curvilinear fashion to the posterior midline
Exception: if an anterior external opening is greater than 3cm from
anal margin then this usually track to the posterior midline.
Categorized based on their relationship to the anal sphincter complex
Treatment is base on this classification
Goal of tx: eradication of sepsis without sacrificing incontinence
Types of anal fistula
Intersphincter fistula
Transsphincter fistula
Suprashincter fistula
Extrasphincter fistula
Complex, nonhealing fistula
a. Intersphincteric fistula
Tracks through the distal internal sphincter to an external opening
near the anal verge
Tx: fistulotomy (opening the fistuluos tract), curettage, and healing by
secondary intention
b. Transsphincteric fistula
From an ischiorectal abscess
Extends through both the internal and external sphincters
 Horseshoe: IO in the posterior midline and extend anteriorly and
laterally to one or both ischiorectal spaces
Tx: sphincterotomy or initial placement of a seton
SETON
Drain placed through a fistula to maintain drainage and/or induce
fibrosis.
Cutting seton: suture or a rubber band that is placed through the
fistula and intermittently tighten
Noncutting seton: soft plastic drain (often a vessel loop) placed in the
fistula to maintain drainage
May be left in place for chronic drainage.
Horseshoe
c. Suprasphincteric fistula
Originates from intersphincteric plane
Tracks up and around the entire external sphincter
Tx: seton
d. Extrasphincteric fistula
Originates in the rectal wall
Tracks around both sphincters to exit laterally, usually in the
ischiorectal fossa
Tx: depends on both the anatomy and the etiology
e. complex, nonhealing fistula
May result from Crohns disease, malignancy, radiation protitis or
unusual infection
PROCTOSCOPY should be performed in ALL cases (assess the
rectal mucosa)
Biopsies should be taken to rule out malignancy
Higher fistulas tx: endorectal advancement flap
Persistent fistulas: fibrin glue
External red elevation of granulation tissue w/ or w/o conccurent
drainage
Internal more difficult to identify; hydrogen peroxide or dilute
methylene blue