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An anal fistula, or abscess, occurs when an anal gland on the dentate line is infected and filled with pus. Usually, an anal abscess refers to the acute phase, and an anal fistula refers to a chronic inflammation in the anus.
In short, an anal fistula usually develops from a previous or current anal abscess. It is a small tunnel that tracks from an opening inside the anal canal to an outside opening in the skin near the anus.
Internal or primary opening is usually located in the anal canal and external openings are in the skin near the anus, and the tunnel that is connecting these openings are called a fistula tract.
Usually, an abscess grows to a fistula when it continues to grow and fill with pus until it bursts. About 70% of abscesses eventually develop into fistulas.
What Causes an Anal Fistula?
Although there are several hypotheses, 90% of fistula cases start with inflammation of the anal gland that is located deep in the cryptogland, forming an abscess between the internal and external sphincters (Cryptoglandular Theory).
Other causes include surgery in the anal area and non-specific chronic enteritis, especially Crohn's disease, diabetes, chronic hemorrhoids, and blood diseases such as leukemia lymphoma, tuberculosis, and actinomycosis.
The main symptoms are slightly different depending on the location and severity of the abscess, but usually involve a stinging pain around the anus, a convex lump with fever and pressure pain, and feeling pain when sitting, walking, or having a bowel movement.
If an abscess grows in a deeper area, the symptoms can appear more gradually, and urinary symptoms such as difficulty in urinating and urinary retention may be accompanied. If it bursts, blood pus continuously comes out and the underwear can be stained, which leads to anal eczema and pruritus.
Most of all, when chronic fistula develops, the majority of patients come to the hospital because of a boil that repeatedly stings and bursts on the skin around the anus, or a streak-like lump underneath the skin.
Diagnosis and classification of the Analysis Fistula
If there is a medical history of having surgery to remove abscess or fistula, the surgical site can grow into a fistula. Anal fistulae usually present with either recurrent perianal abscesses and intermittent or continuous discharge onto the perineum. On examination, an external opening on the perineum may be seen.
If a fistula is already much progressed and complex, it is important to figure out the path of the fistula before surgery through an MRI examination.
Fistulography is sometimes performed to check the path of a recurrent fistula or a stoma. Transanal ultrasonography can be also used to find an abscess.
Treatment of Anal Fistula
The only treatment method that works for abscesses and fistulas is surgery. If left for a long time, it can damage the sphincter, so getting surgery as soon as possible is a fundamental solution.
The purpose of the surgery like incision and drainage of the abscesses is to remove the primary lesion in the intersphincteric plane and treat the primary and secondary fistulas. The traditional incision exposure method is the most popular method to open the fistula by finding internal and external holes. It can artificially create a wound by incising every tissue that is related to the fistula including the sphincters and stimulate skin’s healing process. However, if the sphincter is incised too much, it can cause impairments in the function of bowel control in the future. Therefore, recently, doctors have been trying to keep the sphincter intact as much as possible during surgeries.
Hanley procedure and Sumikoshi’s muscle-filling method are both sphincter-preserving techniques that can reduce the post-surgery relapse rate. Thomson and Ross proposed a method of preserving the external anal sphincter in the treatment of complex transphincteric fistula-in-ano, during which only the internal sphincter is divided and the external anal sphincter is preserved and loosely tied with nylon string. There are also other operative strategies like the one proposed by St. Mark Hospital of UK and Takano procedure of Japan.
Complex anal fistulas like horseshoe fistulas are difficult to remove even by surgery. When all the muscles that are affected by the fistula are incised, it can severely damage the sphincters. So sometimes doctors just block the inner hole or perform surgery twice to avoid incising fistula tract. However, although this surgical method may reduce sphincter damage, there may be a risk of recurrence.
If the fistula biopsy shows general inflammation, surgery alone is sufficient for its treatment, but if it is confirmed as tuberculous fistula, medications for tuberculosis must be taken for at least six months. If it is confirmed as a complication of Crohn’s disease, it also needs intake of appropriate medication along with the surgery.
After having fistula surgery, it is required to put efforts in preventing recurrence (possibility: 0~20%) and fecal incontinence. Therefore, it is important to thoroughly analyze the condition of the fistula and abscess before the surgery, and choose an appropriate surgical method to remove them. It is also important to continue following up and observe conditions of the surgical site during the long recovery period after the surgery.
Prevention of Anal Fistula?
Like other anal diseases, irregular bowel habits such as constipation and frequent diarrhea can cause fistulas. So please regularly consume high-fiber diet and vegetables, avoid excessive drinking or pungent or spicy food, and do aerobic and muscle-strengthening exercises, including the ones for anal muscles.
Above all, if you have any inconvenience or are experiencing any unusual symptoms around the anus, it is highly recommended that you visit a hospital as soon as possible to receive an accurate and prompt diagnosis and treatments.