Perianal Fistula

What is a Perianal Fistula?

By the term anal fistula we mean a tunnel of communication between the anal canal and the skin around the anus. In general, fistulas can appear in various areas of the body but the most common are those located in the anus area. Anal fistulas are very common and  a lot of people are having problems with such fistulas.

Causes

Inside the anus there are many glands that produce fluids under normal conditions. It is possible that at times these glands become blocked for some reason. In this case we have a large concentration of germs and bacteria around the gland which cause inflammation which leads to the formation of an abscess. The abscess will at some point burst through the skin creating a hole. Thus, a communication (tunnel) is created between the inside of the anus and the skin outside. So the fistula connects the gland to the skin. In 90% of cases this is the cause of anal fistula.

Other less common conditions that can cause anal fistulas are:

   – Chron’s disease (inflammatory bowel disease)

    -Radiation to the anus area

    -Injury to the anus

    -Sexually transmitted diseases

   – Diverticulitis

   – Tuberculosis

   – Anal cancer

SYMPTOMS

The main symptom is the discharge of fluid, purulent or serous, from the external opening of the skin. Typically, the patient complains that his underwear gets dirty every day from liquids. Anal fistulas often cause abscesses in the area that appear with severe pain, swelling and redness of the area and require immediate surgical input and drainage of the pus. Other less common symptoms are itching in the area of the fistula, bleeding, pain during bowel movements, and fever.

DIAGNOSIS

The diagnosis of fistula is usually made with the clinical examination by a Surgeon – Proctologist. A careful medical history and examination of the area usually reveals the presence of an anal fistula.

In some cases, it may be necessary to carry out the following tests:

    Magnetic resonance imaging of the anus showing the direction of the fistula.

    Proctoscopy  where with the help of a camera we see the inside of the anus.

    Endorectal ultrasound scan which provides us with information about the type of fistula.

TREATMENT

Unfortunately, there is no conservative treatment for anal fistulas. The treatment is exclusively surgical and belongs to the competence of a specialized colorectal surgeon. The purpose of the operation is to ¨get rid of¨ the fistula while protecting the muscles of the anus which are responsible for defecation and their injury can lead to incontinence.

Depending on the direction  of the fistula in the anal canal, they are divided into the following types:

Intrasphincteric

70%

Transphincteric

23%

Suprasphincteric

5%

Extrasphincteric

2%

It is particularly important to recognize the direction of the fistula and to classify it in the correct category as a different treatment is required in each of them.

Depending on the type of the fistula, we have the following options for surgical treatment:

    Fistulotomy (cross-section of the fistula) which is applied when the fistula  does not penetrate the internal sphincter muscle of the anus. The operation takes a few minutes and the patient leaves the clinic the same day.

    Seton insertion around the fistul. The seton  looks like a rubber band which is progressively tightened  resulting in the gradual excision of the fistula avoiding the direct cross-section of the internal sphincter which would lead to incontinence. It is a painless method and the patient leaves the clinic the same day.

Plastic restoration of the internal opening  with Flap. In this method we close the internal opening with a flap of mucosa from the anus and allow the fistula to heal.

Lift method. In this case, with an incision in the skin, we enter the space between the external and internal sphincter of the anus. Then we ligate the fistula intersphincterically with sutures both towards the internal orifice and towards the external orifice. It is a method used in more complex fistulas.

In the latest years, the endoscopic method of treating fistulas with the VAAFT method (Video Assisted Anal Fistula Treatment) or with the use of laser has also gained popularity. We insert a special thin fiber from the outside opening of the fistula and with the help of the laser we destroy it. At the same time, the internal opening is usually sewn with simple stitches.

FREQUENT QUESTIONS

Which doctor should I contact if I think I have an anal fistula?

The appropriate specialty is the General Surgeon and specifically a specialized colorectal surgeon

 Can anal fistula turn into cancer?

Absolutely NO. Fistulas cannot cause malignancy

I have an anal fistula but it doesn’t really bother me. Should I have surgery?

An anal fistula is not going to heal on its own. It may initially not give particularly disturbing symptoms, but at some point it will lead to an abscess. At the same time, over time it is possible that the existing fistula will expand with branches, which will make it more difficult to treat. Therefore, when the fistula is diagnosed, it must be treated surgically as soon as possible.

Which method is the best to treat the fistula?

The method depends on the type  of the fistula. An experienced colorectal  can identify the appropriate method for each fistula.

Can I have incontinence after the operation?

In the hands of an experienced proctologist the chance of permanent incontinence highly unlikely to happen.

How much does anal fistula surgery cost?

The cost is a combination of the type of operation and patient insurance. In general, it is an operation that does not have a particularly high cost.

How long do I have to be off work if I have surgery?

The return regardless of the method is immediate.

How long does it take to book the operation?

The operation can be performed immediately even the day after the clinical examination.

What kind of anesthesia do I need for the operation?

The operation can be performed either with general or epidural anesthesia.