Anal Fistula

ANAL FISTULA

The formation of an abnormal connection between the mucosal part of the anal canal and the skin is called a "perianal fistula," "anorectal fistula" or "anal fistula." In the large majority of cases, an anal fistula has been found to develop as a result of a previous anal abscess.

How Common Is Anal Fistula?

It is 2 to 7 times more common in men than in women. Patients are between 20 and 60 years of age, with an average age of around 40.

What Causes Anal Fistula?

Where the anal canal meets the skin, there are structures that help keep the anus lubricated and make bowel movements easier. When an infection develops in these structures, a tunnel forms between the rectum and the skin; this is called an "anorectal fistula."

Patients with anal fistula may have a history of constipation and diarrhea.

It has been determined that personal hygiene has no effect on the development of anal fistula.

What Are the Symptoms of Anal Fistula?

• Recurrent anal abscesses
• Anal swelling
• Painful bowel movements and passing of gas
• Rectal bleeding
• Yellowish, sometimes bloody and foul-smelling rectal discharge
• Development of anal dermatitis
• Signs of infection (fever, chills, fatigue)

How Are Anal Fistulas Classified?

Types of anal fistula are distinguished according to the structure and spreading pattern of the fistula:

Intersphincteric Anal Fistula: This is the most common type of anal fistula. It forms when an infection in the anal region spreads between the inner and outer muscles of the anus and drains toward the surface of the skin.

Transsphincteric Anal Fistula: This is the second most common type of anal fistula. It occurs when an abscess formed in the intersphincteric space passes through the outer anal muscle and drains through the skin surface.

Suprasphincteric Anal Fistula: It occurs when an infection in the intersphincteric space first extends inward and then turns toward the surface of the skin.

Extrasphincteric Anal Fistula: It does not originate from anal inflammation. It is one of the rarer types of anal fistula. It can result from a penetrating injury in the rectal area, appendicitis or Crohn's disease (an inflammatory bowel disease).

How Is It Diagnosed?

• MRI (magnetic resonance imaging)
• ERUS (endorectal ultrasound or endoanal ultrasound)
• Fistulography
• Endoscopy

Anal Fistula Treatment

The main principle of treatment is to eliminate the fistula. For this purpose, "fistulotomy" or "fistulectomy" is usually preferred. During surgery, suitable anesthetic agents are applied to the anal area, which reduces the need for painkillers in the postoperative period.

1. Non-Surgical Techniques

• Fibrin Glue Technique:

This technique involves injecting fibrin glue into the fistula tract through a catheter. The success rate is 60–70%, but a high long-term recurrence rate has been reported.

• Plug Technique:

This technique is based on sealing the anal fistula with a plug. Plug material is inserted through the outer opening of the fistula, both openings of the fistula are then stitched closed, and the fistula is allowed to heal naturally. Its success rate today has been found to be between 30% and 50%.

1. Anal Fistula Surgery

• Laser Technique: The fistula tract is closed by laser ablation. A success rate of approximately 70–90% has been reported with laser treatment, especially in patients with complex anal fistulas. The main goal is to seal the cavity with the laser, much like filling it with silicone. It is a current technique associated with little rectal pain after surgery.
• Apart from the Laser Technique, various other techniques are available, such as the VAAFT technique, the LIFT technique, the seton technique, fistulotomy or fistulectomy, two-stage fistulectomy, leaving the wound to heal by secondary intention, fistula closure, endorectal advancement flap, anoplasty with a skin island flap, and the York-Mason procedure.
• Seton technique: A seton is a thin thread placed in the fistula in the shape of a ring or loop. It may be made of flexible rubber or silicone. The fistula drains outward along the seton, which aims to prevent abscess formation in the surrounding area.

After anal fistula surgery, warm sitz baths are often recommended. A sitz bath can be taken in a bathtub or basin, or special plastic sitz bath tubs designed to fit inside the toilet can be used.

Can Anal Fistula Lead to Cancer?

If an anal fistula persists for more than 8–10 years, anal cancer may develop, although this is rare.

OTHER RECTAL DISEASES

Diagnosis and treatment methods for some common rectal diseases:

Hemorrhoids

In healthy people, the anal region contains structures called cushions, which contain blood vessels, connective tissue and smooth muscle. Due to chronic constipation or diarrhea, excessive straining, poor toilet habits or pregnancy, these cushions enlarge and sag, turning into hemorrhoids (piles).

Treatment options include simple measures, hemorrhoid medications, and non-surgical and surgical treatment methods.

Simple measures include:

• A high-fiber diet,
• Probiotics,
• Natural remedies (using plants)
• Sitz baths (sitting in warm water for 10–15 minutes, 4–5 times a day)
• Creams.

In addition, hemorrhoidal tissue can be treated with laser procedures in a short and generally painless procedure, without any stitches.

Anal Abscess

An anal abscess is an infected, pus-filled cavity located next to the anus or rectum. Symptoms may include rectal pain, swelling in the anal area, purulent and foul-smelling discharge from the anal area, constipation, difficulty passing stool, chills, shivering, weakness and fatigue.

Treatment: anal abscesses may drain on their own, or surgical intervention may be needed. After drainage, rectal pain and the feeling of pressure in the rectum ease and disappear. Large and deep abscesses must be drained in the operating room under general anesthesia, while superficial abscesses can be drained under local anesthesia. If left untreated, they often recur.

Rectal Prolapse

Protrusion of the rectum out through the anal canal, or its descent into the anal canal, is called "rectal prolapse." As a result of weakening of the anal muscles, involuntary leakage of stool or mucus from the rectum may occur. It is often seen after multiple childbirths.

Treatment: both surgical and non-surgical treatment options are available.

Non-surgical treatment includes methods such as diet, radiofrequency application, acupuncture and the application of granulated sugar (which has been found to partially reduce edema in the rectum); however, if the condition does not improve despite these measures, surgery is required.

Pilonidal Sinus

A pilonidal sinus occurs when hairs penetrate under the skin and cause a wound, abscess and fistula. There is a hair-containing sinus or abscess in the cleft between the buttocks. It is much more common in men than in women. Hairs penetrate (are drawn into) the skin, and a hair nest forms beneath the skin.

It develops in hairy, slightly overweight young men aged 16–30 due to hormonal effects on the hair and sebaceous glands. Excessive friction in the genital area, heavy sweating, obesity, poor hygiene and local trauma are among the risk factors.

Treatment: It can be treated locally or with surgery. If there is an abscess, it is drained. Many surgical methods are used in treatment. Local treatment options include removing a small area containing the pilonidal sinus under local anesthesia, laser treatment, and the frequently preferred silver nitrate applications.

Sexually Transmitted Anorectal Diseases

Risk Factors:

• People aged 16–25
• A change of sexual partner two or more times a year, or a change of sexual partner in the last 3 months
• Having multiple sexual partners
• Low socioeconomic status
• Black race
• Sexual contact without a condom
• Having sexual contact with a person diagnosed with a sexually transmitted anorectal disease

Sexually transmitted anal diseases are grouped as viral (HPV, herpes, AIDS, anal cancer, hepatitis B–C, …), bacterial (gonorrhea, syphilis, chlamydia, chancroid, …), fungal diseases and parasites.