Clinical Specialties
The GW Medical Faculty Associates is an elite, academic medical team delivering care through 51 medical and surgical specialties.
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Anal Fistula
SYMPTOMS
Drainage of feces outside the anus, recurrent abscesses in the anal area, pain in the anal area, drainage of pus or blood around the anus
DIAGNOSIS
The diagnosis of anal fistula is made by a careful history and thorough physical exam. Likely, the physical exam will include a digital rectal exam which involves insertion of a gloved finger into the anal canal. It is important for your surgeon to determine the path of the fistula to determine which type you have. Your doctor may be able to feel the path of the fistula as a hard cord beside the anus, but he or she may also need other tools to help locate the path of the fistula. Your surgeon may use a fistula probe (which is placed in the fistula to determine its direction) or may place a small plastic device called an anoscope into the anal canal to get a better look. There are also many ways to visualize the canal like putting dye in the rectum (diluted methylene blue dye test), injecting contrast and taking a picture (fistulography), or MRI to visualize the path of the fistula. Your doctor may also want to use a small scope with a camera at the tip to look into the colon with either a flexible sigmoidoscopy or colonoscopy.
TREATMENT
Several treatment options for anal fistula exist. Your surgeon will discuss the best options to close the fistula while preserving the surrounding muscles. A fistulotomy, or lay-open of the fistula, is done by probing the fistula and cutting it open to clean out the contents (including harmful bacteria) and then sewing it flat against the incision already made. This type of wound left behind will need to be packed with clean gauze for weeks after the procedure. Your surgeon may choose to surgically remove parts of the fistula as well, especially if your fistula is complicated with multiple turns. This procedure may be done all at once or may take several small operations to try and preserve the anal sphincter muscles. If your surgeon thinks that sparing the sphincter muscles is important, he or she may cut out the fistula as well as a larger flap from the wall of the rectum to remove the internal opening of the fistula, sew closed the fistula, then pull the flap back down and sew it in place (an advancement flap). Another option your surgeon may recommend is seton placement. In this procedure, the surgeon uses a string or small rubber band (a seton) to help create scar tissue in the area of the fistula and allow the seton to wear its way through the muscle over several weeks time, obliterating the fistula. The seton can be permanently left in place to allow the fistula to drain (and prevent recurrent abscess) or can be surgically opened to remove the fistula. A final surgical option is a fibrin glue or collagen plug, both of which are biodegradable, which is placed in the fistula with the opening sewn closed which theoretically allows the fistula to heal from the inside. You should have an interactive discussion with your surgeon about the best option for you and your particular fistula.
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