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An anal fistula can be defined as an abnormal connection between the inner surface of the anus and the skin surrounding it. It may present as a single channel or, in some cases, multiple tracts. The location and pathway of these tracts are extremely important because this region contains muscles that are vital for normal function. Therefore, the extent to which these muscles are affected is also critical.
When a fistula develops, there is often a persistent discharge of pus. Although many patients expect it to heal on its own, the likelihood of spontaneous resolution is very low. For this reason, early diagnosis and treatment are essential. Before discussing diagnosis and treatment, it is important to understand the difference between fissure and fistula.
What Are Fissure and Fistula?
Fissure and fistula are often confused due to their similar pronunciation, but they are entirely different conditions, even though they occur in the same region. An anal fissure is essentially a tear in the anal canal caused by strain. These deep cracks can expose the muscles at the end of the large intestine. It is more common in individuals with hemorrhoids or chronic constipation. Symptoms include pain, bleeding, itching, and swelling, with pain during defecation being the most common.
An anal fistula, on the other hand, develops as a result of infection in the anal region. It often begins with an abscess that causes pain, and although drainage may temporarily relieve symptoms, it is usually the first sign of fistula formation. It appears as small openings or channels around the anus. These areas may become infected and form abscesses. Diagnosis is often made through a simple physical examination.
What Causes Anal Fistula?
The most common cause is infection of the glands located beneath the skin and between the muscles around the anus. Other causes include:
- Acute diarrhea episodes
- Trauma from hard stool or foreign objects
- Infected anal fissures
- Inflamed anal hematomas
- Intestinal parasites
- Pinworms
- Ulcerative colitis
- Tuberculosis
- Fungal infections of the intestine
- Cancer
- Lower abdominal infections
- Genital infections
- Crohn’s disease
- Diverticulitis
Symptoms of Anal Fistula
Symptoms may vary from patient to patient but commonly include:
- Swelling around the anus
- Pain in the anal region
- Itching and burning
- Difficulty sitting
- Redness around the anus
- A feeling of fullness
- Foul-smelling or bloody discharge
- Fever
- Pain during urination
- Constipation
- Yellow stains on underwear
How Is It Diagnosed?
In most cases, diagnosis can be made through physical examination alone. However, if discharge stops or the fistula opening is internal, imaging techniques may be required. MRI and colonoscopy are commonly used to determine the extent and pathway of the fistula and whether there is an associated abscess or underlying disease.
Types of Anal Fistula
- Transsphincteric fistula
- Suprasphincteric fistula
- Extrasphincteric fistula
- Intersphincteric fistula
How Is It Treated?
Anal fistula rarely heals on its own, and waiting for spontaneous recovery can lead to worsening of the condition. The primary treatment is surgical intervention. Antibiotics may be used as supportive therapy, but medication alone is not sufficient.
Surgery involves opening and cleaning the infected tract. Because the anal sphincter muscles may be affected, it is crucial that the procedure is performed by an experienced surgeon. In complex cases, advanced techniques such as mucosal advancement flaps, staged fistulotomy, or seton placement may be used.
Anal Fistula Surgical Treatments
Perianal fistula cannot currently be treated with medication alone.
- 1- Fistulotomy
Used when the fistula involves only a small portion of the sphincter muscles.
- 2- Fistulectomy
Preferred for simpler fistulas. The tract is opened and left to heal naturally.
- 3- Fibrin glue
A special adhesive is used to close the fistula tract, though success rates are lower.
- 4- Laser treatment
The tract is cauterized using a laser from the inside out.
What Is the Seton Technique?
This technique involves placing a medical thread through the fistula tract and gradually tightening it. This allows the sphincter muscle to be divided slowly and safely. The success rate ranges between 80% and 100%.
Recurrence is common in all surgical treatments.
Why Does It Recur After Surgery?
The most important factor is surgical experience. If the procedure is not performed properly, recurrence rates are high. Additionally, damage to the sphincter muscles during surgery may lead to incontinence. Therefore, careful evaluation and choosing an experienced surgeon are essential.
