Anal fistulas are recently becoming frequent mainly due to poor dietary habits and poor intake of fluids this leads to attacks of severe constipation which is the main cause of anal fistulas. Other causes of anal fistulas include inflammatory bowel disease like Crohn’s disease, trauma, sexually transmitted disease tuberculosis and cancer.
Inside the anus there are a number of small glands that make mucus that help in stool passage during defecation. Occasionally, these glands get blocked by hard stool particles and can become infected leading into an abscess. About 50% of these abscesses may develop into an anal fistula which is a small canal that opens internally in the ano-rectal area and externally around the anus.
The signs and symptoms of an anal fistulas include frequent anal abscesses with pain and swelling around the anus. These abscesses either self-drain or are surgically drained with the formation of a perianal draining sinus opening that may drain continuously or on and off with bloody or foul-smelling pus drainage. The pain usually decreases after the fistula drains. This is associated with irritation of the skin around the anus from the drainage.
There are 4 types of anal fistulas:
-Intersphincteric fistula where the tract pierces the internal anal sphincter, passes in the space between the internal and external anal sphincter muscles and opens close to the anal opening.
-Transphincteric fistula where the tract passes through the internal and external sphincter muscles and opens usually within few centimetres from the anal opening. These fistulas can go around the anal canal with multiple external openings on both sides of the anus (so called a horseshoe fistula).
-Suprasphincteric fistula where the tract turns upward to a point above the puborectal muscle and then goes down to open away from the anus.
-Extrasphincteric fistula where the tract usually begins at the recto-sigmoid colon and extends downward to pass through the levator ani muscle and opens around the anus. These fistulas are usually caused by inflammatory bowel disease like Crohn’s disease and can be multiple.
Anal fistula are diagnosed on anal digital rectal exam and anoscopy which reveal the external opening of the fistula and may even detect the internal opening. A pelvis MRI with contrast is almost always mandatory to delineate the fistula tract type, its relation to the anal sphincters and any branching or deep abscesses. Colonoscopy may be advisable if Crohn’s disease is suspected.
Treatment of anal fistulas varies with its type and complexity. For simple low type fistulas, laying open of the fistula tract by laser and radiofrequency followed by curettage and leaving the wound to heal by itself in a couple of weeks is advisable.
More advanced or complex fistulas especially with the presence of an abscess may however need staged procedure with usually lasering of the fistula tract and insertion of a draining seton being the first step. This will help to resolve the infection and inflammation and downgrade the fistula. The second stage (final stage) will be done in 2-3 months depending on the clinical follow up and it consists of different advanced minimally invasive, sphincter preserving and minimally painful procedures depending on the fistula type.
– Laser anal fistulectomy (FiLaC)
– FiLaC with VAAFT (video assisted anal fistula treatment) with or without mucosal advancement flap closure of internal fistula opening.
– FiLaC with LIFT (ligation of intersphincteric fistula tract)
– FiLaC with SLOFT (submucosal ligation of fistula tract)
Permacol paste may be added to the above in case of wide fistula tract to help in the closure or in case where an internal opening is not detected in some high complex anal fistulas.
We at Veincureclinic/Emirates health group are specialized and pioneered in treating anal fistulas complex and simple with excellent results using the latest technology and with minimal pain and a day surgery setting where the patient can go back to his normal life immediately after surgery with no alteration in his life style.
Written by Dr. Luay Hajjar