Fistula In Ano
FISTULA IN ANO
Chronic communication between the epithelialized
surface of the anal canal or rectum to the perianal skin
Often occurs following Anorectal Abscess.
Drainage of an Anorectal Abscess:
50% Cure
50% Fistula In Ano
Origin:
Cryptoglandular (Majority)
Trauma
Crohn’s disease
Malignancy Radiation
Unusual infections (Tuberculosis, Actinomycosis, and
Chlamydia)
DIAGNOSIS
Clinical Manifestations
Persistent drainage from the internal and/or
external openings.
Physical Examination (Mainstay)
Identify:
External Opening Easy
visible as a red elevation of granulation tissue
w/ or w/o concurrent drainage.
Internal Opening Challenging
Goodsall’s rule
Injection of hydrogen peroxide or dilute
methylene blue (helpful)
Goodsall’s rule
identify the location of the Internal Opening
External opening Anteriorly connect to the internal
opening by a short, radial tract
External opening Posteriorly connect to the internal
opening by a curvilinear tract to the posterior midline
Exceptions:
Anterior external opening is greater than 3 cm from the
anal margin.
Such fistulas usually track to the posterior midline.
4 Major Categories:
based on their relationship to the anal sphincter complex
• Intersphincteric Fistula • Tracks through the distal internal
sphincter and intersphincteric space to an
external opening near the anal verge
• Transphincteric Fistula • Results from an ischiorectal abscess
• Extends through both the internal and
external sphincters
• Suprasphincteric fistula • Originates in the intersphincteric plane
and tracks up and around the entire
external sphincter
• Extrasphincteric fistula • Originates in the rectal wall and tracks
around both sphincters to exit laterally, Intersphincteric
usually in the ischiorectal fossa Fistula
4 Major Categories:
based on their relationship to the anal sphincter complex
• Intersphincteric Fistula • Tracks through the distal internal
sphincter and intersphincteric space to an
external opening near the anal verge
• Transphincteric Fistula • Results from an ischiorectal abscess
• Extends through both the internal and
external sphincters
• Suprasphincteric fistula • Originates in the intersphincteric plane
and tracks up and around the entire
external sphincter
• Extrasphincteric fistula • Originates in the rectal wall and tracks
around both sphincters to exit laterally, Transphincteric
usually in the ischiorectal fossa Fistula
4 Major Categories:
based on their relationship to the anal sphincter complex
• Intersphincteric Fistula • Tracks through the distal internal
sphincter and intersphincteric space to an
external opening near the anal verge
• Transphincteric Fistula • Results from an ischiorectal abscess
• Extends through both the internal and
external sphincters
• Suprasphincteric fistula • Originates in the intersphincteric plane
and tracks up and around the entire
external sphincter
• Extrasphincteric fistula • Originates in the rectal wall and tracks
around both sphincters to exit laterally, Suprasphincteric Fistula
usually in the ischiorectal fossa
4 Major Categories:
based on their relationship to the anal sphincter complex
• Intersphincteric Fistula • Tracks through the distal internal
sphincter and intersphincteric space to an
external opening near the anal verge
• Transphincteric Fistula • Results from an ischiorectal abscess
• Extends through both the internal and
external sphincters
• Suprasphincteric fistula • Originates in the intersphincteric plane
and tracks up and around the entire
external sphincter
• Extrasphincteric fistula • Originates in the rectal wall and tracks
around both sphincters to exit laterally, Extrasphincteric Fistula
usually in the ischiorectal fossa
TREATMENT
Goal eradication of sepsis without sacrificing continence
Surgical treatment is dictated by the location of the internal and
external openings and the course of the fistula.
Simple Intersphincteric fistulas
Fistulotomy (opening the fistulous tract), curettage, and healing by
secondary intention
Transsphincteric fistula
Depends on its location in the sphincter complex
Include less than 30% of the sphincter muscles sphincterotomy
without significant risk of major incontinence
High Transsphincteric fistulas (encircle a greater amount of muscle)
More safely treated by initial placement of a SETON
Suprasphincteric Fistulas
Usually treated with seton placement
Extrasphincteric Fistulas
rare, and treatment depends on both the anatomy of the fistula
and its etiology
Complex and/or nonhealing fistulas
Proctoscopy
assess the health of the rectal mucosa
Biopsies of the Fistula tract
Rule out malignancy
Seton
drain placed through a fistula to maintain
drainage and/or induce fibrosis
Cutting setons
consist of a suture or a rubber band that is
placed through the fistula and intermittently
tightened in the office
Noncutting setons
soft plastic drain (often a vessel loop) placed in
the fistula to maintain drainage
Endorectal advancement flap
Higher fistulas
Fibrin glue and a variety of collagen-based
plugs
persistent fistulas
variable results
Ligation of the intersphincteric fistula tract
(LIFT)
recent technique and also shows promise
In this procedure, the fistula is identified in the
intersphincteric plane (usually by placement of a
lacrimal probe), divided, and the two ends ligated
Early reports have shown success with this
technique, but long-term outcome is not yet
known.
