Anal Fistula

What is anal fistula?

Anal fistula [fistula-in-ano] is a condition best described as the formation of an infected tunnel in the anus.  Typically, the tunnel has an entry side (opening inside the anus) and an exit side (opening on the skin surrounding the anus). Anal fistula affects both genders from early childhood to adulthood but it is most commonly seen in men between the age of 30 and 50 years.   The tunnel can take various courses through the anus and the sphincter muscle [Figure 1].

Figure 1 – Various types of anal fistula

What causes anal fistula?

Multiple small glands are inside the anus.  The glands make secretions and contribute to the normal function of the anus.  In the majority of patients, an anal fistula is caused by an infection of one of the glands.  Less common causes of anal fistula include inflammatory bowel disease such as Crohn’s disease, atypical infections such as tuberculosis, previous proctologic surgery, childbirth injuries, cancer, and prior radiation therapy.

What are the symptoms of anal fistula?

Patients with anal fistula can present initially with an Anal Abscess that drains spontaneously or that requires a surgeon to drain it through the skin.  Patients with an abscess have one or more of the following symptoms: severe pain, swelling, redness, fever, chills, fatigue, and/or pus drainage (a thick creamy whitish or yellowish secretion) from the anus or the skin.  Some patients present with an established fistula without a prior history of abscess.  Presenting symptoms include pus or blood drainage from the skin or anus, intermittent swelling, skin itching, and/or a skin opening with a nodule.

How is anal fistula diagnosed?

The history and physical examination are sufficient to make the diagnosis of anal fistula.  An office-based examination includes visual inspection, probing the skin opening with a very thin probe, and an anal examination using the finger and Anoscopy or Proctoscopy to look inside the anus and rectum.  Occasionally, Dr. Maher Abbas may recommend an endoanal ultrasound or MRI (magnetic resonance scan) to further assess the deeper aspect of the fistula.  Some patients are advised to undergo Colonoscopy to assess the large bowel (colon and rectum).  Colonoscopy is a very important test especially if the patient has any abdominal symptoms, rectal bleeding, or fistula features suggestive of the possibility of inflammatory bowel disease.

How is anal fistula treated?

In general, there is no medical cure for anal fistula without a surgical procedure.  Anal fistula is a nuisance and most patients elect to have it treated surgically in order to heal.  Patients who present with an abscess are advised to undergo drainage of the abscess as the initial step along with taking antibiotics, pain medications, High Fiber Food and Fiber Supplements, and having a Sitz Bath.   On some occasions and depending on the type and complexity of the abscess, a small mushroom catheter [Figure 2] is inserted inside the abscess cavity to improve the healing.  In patients with a clearly established fistula tract, a seton drain [Figure 3] is placed to facilitate subsequent procedures to heal the fistula.

Figure 2 – A mushroom catheter

Figure 3 – A seton drain

Patients with anal fistula can benefit from the extensive expertise of Dr. Maher Abbas treating patients with simple and complex fistulas.  As an expert in the field of proctology and colorectal surgery, he offers the entire spectrum of operations.  Dr. Maher Abbas believes in customizing the patient’s care according to his/her individual situation.   The goal of anal fistula treatment is to get rid of the fistula, minimize the risk of the procedure, preserve anal function and continence, and avoid relapse or recurrence of the fistula.  The deeper the fistula and more anal sphincter muscle involved, the more complex the care needed.  While most patients require 1 procedure to heal, the patients with complex fistulas can require more interventions.  Based on your condition, Dr. Maher Abbas will recommend the best operation for you.  The following are the various treatment options:

• Seton insertion. This simple procedure entails inserting a string through the fistula tract to allow for proper drainage.  Often this intervention is performed in preparation for a second procedure.  In rare occasions, the seton is gradually tightened to slowly rid of the fistula
• Minimally Invasive Procedures for Fistula. Laser and videoscopic procedures can be good options for some patients with deep fistulas
• Fistula removal (fistulotomy or fistulectomy). The fistula is removed and the wound is left open to heal
• Fistula removal with anal sphincter reconstruction. This procedure allows for removal of the fistula and repair of the muscle to preserve its function
• LIFT procedure (Ligation of the intersphincteric fistula tract). This operation allows the surgeon to divide the fistula close to the internal opening inside the anus.  It is typically performed in 2 stages
• Endorectal advancement flap. Patients with deep and complex fistulas can benefit from this operation which allows for closure of the internal opening using the tissue of the rectal wall
• Injectables and anal plugs. These procedures typically carry lower long-term fistula closure rate but maybe appropriate in a minority of patients
• Other more advanced procedures are offered for highly complex fistulas and they include the use of adjacent muscle

• New advances currently in development. Several new technologies are on the horizon and include stem cell therapy, plugs, and biodegradable clips.  These therapies are currently under study and may become available in the near future

For additional information on the various treatment options for anal fistula, click here.

What happens if a fistula is left untreated?

Anal fistula is a nuisance that negatively impacts a person’s quality of life.  It is usually not dangerous but untreated it can become more complicated by forming additional tracts and fistulas.  Furthermore, a fistula that does not drain properly can form more serious infections including deeper abscess.  On rare occasions, an untreated fistula for 10 or more years can develop into cancer.

Why is it important to seek expert care with a board certified proctologist and colorectal surgeon?

The anal area is a delicate part of the body.  It is important to seek expert care in order to heal and obtain the best long-term results.  The expertise of the doctor is critical in order to minimize the risk of relapse, non-healing, infection, and weakness of the muscle. Furthermore, some patients need additional work-up such as  Colonoscopy  to exclude other causes of anal fistula.

Dr. Maher Abbas is an expert in the treatment of diseases of the colon, rectum and anus.  With over a 30-year career in the USA, he has completed advanced surgical training and is American Board Certified in Colon and Rectal Surgery.   Dr. Maher Abbas is a Fellow of the American Society of Colon and Rectal Surgeons.

If you would like to schedule a consultation with Dr. Maher Abbas to discuss your case, click here.