Part of the TeachMe Series

Anal Fistula

star star star star star
based on 12 ratings

Original Author(s): Will Hunt
Last updated: October 27, 2019
Revisions: 35

Original Author(s): Will Hunt
Last updated: October 27, 2019
Revisions: 35

format_list_bulletedContents add remove

A perianal fistula (fistula-in-ano) refers to an abnormal connection between the anal canal and the perianal skin.

The majority are associated arise from anorectal abscess and around one third of patients with an anorectal abscess will have an associated perianal fistula at the time of presentation.

Aetiology

The formation of an perianal fistula typically occurs as a consequence of an perianal abscess (over 90% secondary to a perianal fistula).

Other risk factors include:

  • Inflammatory bowel disease – Crohn’s disease or ulcerative colitis
  • Systemic diseases – Tuberculosis, diabetes, HIV
  • History of trauma to the anal region
  • Previous radiation therapy to the anal region

Clinical Features

Anal fistulae usually present with either (1) recurrent perianal abcesses (2) intermittent or continuous discharge onto the perineum, including mucus, blood, pus, or faeces.

On examination, an external opening on the perineum may be seen; these can be fully open or covered in granulation tissue. A fibrous tract may be felt underneath the skin on digital rectal examination.

The Goodsall Rule

The Goodsall rule can be used clinically to predict the trajectory of a fistula tract, depending on the location of the external opening:

  • External opening posterior to the transverse anal line – fistula tract will follow a curved course to the posterior midline
  • External opening anterior to the transverse anal line – fistula tract will follow a straight radial course to the dentate line
Fig 2 - The Goodsall rule, used clinically to predict the course of a fistula tract.

Figure 1 – The Goodsall rule, used clinically to predict the course of a fistula tract

Investigations

Proctoscopy can be used to visualise the opening of the tract in the anal canal. For complex fistula, MRI imaging is often required to visualise the anatomy of the tract.

Park’s classification system divides anal fistulae into four distinct types (Fig. 2):

  • Inter-sphincteric fistula (most common)
  • Trans-sphincteric fistula
  • Supra-sphincteric fistula (least common)
  • Extra-sphincteric fistula
Fig 3 - Diagram highlighting the positions and nomenclature for anorectal fistulae

Figure 2 – Diagram highlighting the positions and nomenclature for anorectal fistulae

Management

The definitive management for an anal fistula depends largely on the cause and site. Indeed, if the patient has no symptoms, a conservative approach may be used. Varying surgical options are available for those deemed not suitable for conservative approach

Surgical Treatment

Cochrane Review concluded that there is no difference in recurrence rates between the various techniques used in the surgical treatment for anal fistulae. The most common methods employed are laying open of the tract or seton insertion.

  • fistulotomy (suitable for superficial / submucosal fistulae) involves laying the tract open and allowing it to heal by secondary intention. A probe is passed along the tract, allowing the the skin and subcutaneous tissue* to be divided in turn, to lay the tract open.
  • The placement of a seton (a rubber sling) though the fistula promotes through the tract and the opening of the perianal skin adjacent to the external opening, attempting to bring together and close the fistula, also preventing abscess formation

It is quite common for patients with complex anal fistulas to require several procedures over months or years.

*If the fistula has a low track course (whereby the tract travels through less subcutaneous tissue and muscle) continence is rarely impaired post-operatively, however if the fistula has a high tract course then there is a higher chance of impairment in continence

Key Points

  • An anal fistula is an abnormal connection between the anal canal and the perianal skin
  • Most fistulae can be investigated via proctoscopy, to visualise the opening of the tract within the anal canal
  • Any patient with an anal fistula or recurrent peri-anal abscesses should be investigated for possible Crohn’s disease
  • There are multiple surgical management options available, none of which have been shown to be superior in outcomes