Anal Fistula - Symptoms, Causes, Prevention, Treatment

FIstula in Ano

1. Fistula in Ano (Anal Fistula) is an abnormal passage or tunnel between the anal canal and skin near the buttocks. 
2. The opening in our body from where faeces are expelled is called the anus.
3. The fistula of the tunnel has 2 openings Internal (towards the anal canal) and external on the skin.
4. It usually occurs due to infection and pus collection in anal glands which drain and develop into a fistula.
5. Fistula is often confused with Piles or haemorrhoids.

Fistulas may be simple or complex in structure.

1. Simple Fistula- It occurs mostly due to glandular obstruction resulting in an abscess. It has a single tract and is easy to diagnose and treat, having a  low recurrence rate and fewer complications. Surgical treatment is required.
2. Complex Fistula- These are recurrent fistulas with multiple tracts and are mostly associated with some underlying diseases like Crohn's disease, inflammatory disease of the rectum, or radiation.

An anal fistula is generally caused by blocking the anal glands, which builds up the bacterial infection forming an inflamed pocket of infected tissues and liquids that result in an anal abscess which finds its way out through the skin(surgically drained and spontaneous rupture). 

Uncommonly It also develops from other conditions:-(Complex Fistula)

Ulcerative colitis and Crohn's disease

1. Tuberculosis
2. Sexually transmitted disease
3. Trauma
4. Anorectal cancer

Symptoms of Anal Fistula

The symptoms are not limited to these, and these usually follow a repetitive cycle,

The most common symptoms of fistula in ano are –

1. Painful bowel movement and urination.
2. Itching and irritated skin in the perianal region
3. One might be able to feel the external opening around the anus.
4. Frequent anal abscesses.

If the fistula is associated with an abscess, you may experience:

1.  throbbing pain in the rectal area due to the formation of an abscess
2. Swelling and redness around the anus suggest a collection of pus and the formation of an abscess
3. Fever
4. Repetitive cyclical foul smell discharge once every 4 to 8 weeks. 
5. Bleeding from anus
6. Discharge pus from anus

Diagnosis

 

1.  Physical examination:

Inspection of the skin surface near the anal area will be done by the doctor to check tenderness and pus discharge after reviewing the patient’s medical history and symptoms. 

      2.   Rectal Examination:

The doctor may insert his finger in the anus(using lubricant and wearing gloves) to locate the fistula opening and look for signs such as oozing fluid or bleeding.

     3 . Proctoscopy- The fistula probe is attached to a specialized telescope with a light on one end to see inside the rectum and visualize the fistula.

      4.Investigations:

1. Other diagnostic tests performed to locate the exact fistula tract:
2. Anal Endosonography-  Ultrasound images of the pelvic floor area help to determine the location of the fistula tract.
3. Fistulography- A contrast dye is injected into the fistula tract and X-rays are taken to visualize the path of the tract.
4. MRI( Magnetic Resonance Imaging)- It is considered the gold standard in the diagnosis of anal fistulas. MRI scans can even define complex and recurring fistulas due to high soft tissue resolution.

Treatment

Anal fistula does not heal completely on its own, surgery is necessary to treat it. A fistula associated with Crohn’s disease can be attempted to treat with medications as surgical success rates are low.

 The main aim of surgery is to get rid of the fistula while protecting the anal sphincter muscles(a ring of muscles that controls opening and closing of the anus) which might cause bowel incontinence(loss of bowel control) if damaged.

Home remedies for acute pain relief:

1. Some self-care measures may help to relieve pain and discomfort:
2. Sitz bath.
3. Eat healthily and take more fibrous food, include honey, oregano oil, flax seeds in your diet and apply coconut oil to the anal sphincter.
4. Drink plenty of water and fruit juices.
5. Avoid alcohol.
6. Add ginger tea and turmeric milk to your daily diet. This will help in preventing constipation.
7. An excess amount of water makes stool soften and also helps to clean the intestine. OTC Stool Softeners might also be useful in the acute stage.

 Medications- Painkillers can be taken over the counter on the doctor’s advice.

Ayurvedic management:

1. Abhyangam
2. An ayurvedic massage with special oils and in specific directions relieves pain.
3. Avagaha Sweda 
4. After an oil massage, sitting in neck-deep warm water infused with ayurvedic herbs. It aids in rejuvenation and relieves pain.
5. Dhumpana
6. A medicinal smoke therapy that relieves pain caused due to anal fistula
7. Kshara Sutra
8. It is a seton thread medicated with ayurvedic medicine inserted into the fistula tract which acts as an antiseptic and aids in the healing of the fistula. The mechanical action of thread and the therapeutic action of the medicine coated on the thread act collectively to promote healing.
9. Other Ayurvedic herbs such as Triphala, Guggulu, Haridra, Jatyadi Ghrita are used for symptomatic treatment.

Surgical Management

Surgery is considered the gold standard treatment for fistula as it results in a permanent cure. Several surgical techniques are available depending upon the location and severity of the fistula( simple or complex).

These are some surgical techniques:

1. Fistulotomy: This is the most common and effective treatment for patients with simple fistulas. In this procedure, the surgeon cuts off the whole length of the fistula so it can heal as a plain scar. It is generally an outpatient procedure. You can go home the same day.
2. Seton techniques: In this procedure, the surgeon tightened the fistula with the help of a suture or rubber band. It heals the fistula behind the seton and also lowers the risk of incontinence. Recommended for long, complex and high fistulas.
3. Laser surgery: In this procedure, a small laser fibre is inserted into the track and the laser seals the tract with heat and coagulation.
4. Advancement Flap procedure

          In this procedure, the fistula is scraped and then the internal opening of the track is closed with a piece of tissue or skin called the advancement flap( taken from the rectum or anus).

          This is used to treat fistulas passing through the sphincter muscles to avoid intontinence. It has a lesser success rate than fistulotomy.

          5. LIFT-ligation of the intersphincteric fistula tract 

1. It is a new technique for fistulas associated with anal sphincter muscles. Here the skin above the fistula is opened, the sphincter muscles are pushed apart and the internal opening of the fistula is ligated (tied off)with a suture. The infected tract is then removed and the wound is cleaned and scraped thoroughly. This procedure can be used as a second stage for the seton technique.

Non-Surgical Management

Fibrin Glue method

1. In this technique, the internal and external openings of the fistula tract are identified and cleaned thoroughly. A Special glue made from a fibrous protein (fibrin) is then injected into the tract which seals the fistula and aids in healing.

 

Anal Fistula treatment  helps in 

1) Respite from the bad odour discharge from the anal region , which is quite embarrasing

 

1. Recurrence of fistula
2.  Anaemia
3. Unbearable Anal Pain
4. Development of multiple anla fissures
5. Extension of anal Fissures
6. Anal Stenosis
7. Fecal incontinence
8. Strangulation