An Anal Fistula is an abnormal "tunnel" or tract between the anal canal (anus) and the external buttock skin. In normal individuals, this channel should not exist and the faeces in the anal canal should only be contained within it.
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The most common symptom of an anal fistula is staining of the underwear.
Most patients first seek medical consult when they notice some yellowish stains or a small amount of faeces on the underwear. Patients often mistook this for faecal incontinence, and it is a common initial diagnosis. The giveaway is usually a discordance of the patient’s age with the diagnosis, as faecal incontinence usually occurs in the elderly or patients who have had previous anal surgery.
The second commonest symptom is the discovery of a small pimple-sized lump beside the anus or on the buttock. The lump is only minimally tender though some patient may report having squeezed out some yellowish discharge or faeces from the lump.
Lastly, some patients may only be diagnosed after they have repeated episodes of buttock abscesses. The reason behind this is the continuous tracking of faeces and other infected material along the channel to the skin with repeated episodes of infection and pus collection.
An anal fistula usually starts with an infection that arises from the anal glands in the anal canal. This infection then tracks towards the buttock skin and form a swollen pocket of infected tissue and liquid (an abscess). This is known as a perianal or ischiorectal abscess.
The abscess may either spontaneously burst and discharge pus. If it doesn't, a patient will have to undergo surgery to drain it. In either scenario, some of the patients will have the original channel persisting and staying open, and this eventually forms a permanent pathological channel between the anal canal and the skin.
In a minority of the cases, anal fistulas arise as a result of an underlying condition called Crohn's Disease. Patients with Crohn's disease can have multiple fistulas that do not heal.
Surgery for anal fistulas involves elimination of the abnormal channel. There are three main surgical approaches.
An anal fistulotomy is the most employed approach to fistulas with the best results. This involves laying open of the channel and cleaning it out to encourage healing. Some anal sphincter muscle involved in maintaining faecal continence will be divided during this procedure. If care is taken to avoid dividing too much muscle, the chance of faecal incontinence after surgery is very low.
A second approach is known as the LIFT (Ligation of Inter-Sphincteric Fistula Tract) procedure. The LIFT procedure is a fairly recent technique developed by Prof Arun Rojansakul. It offers the advantage of dealing with complex or high fistulas with minimal risk of faecal incontinence.
The third approach involves the placement of a suture or a rubber tie through the fistula channel, the anal canal and the external skin. This approach is a two-stage surgery, with the first stage involving placement of the seton and the second stage involving either a fistulotomy or a LIFT procedure. The principle behind a seton is to allow the suture or the rubber tie to gradually cut down on the channel and increase the chance of success and decrease the complication rate of the second surgery.
There will be a wound after a fistulotomy procedure. This will require regular washing during baths and after passing motion. No particular dressing is required except for a pad to be placed over the underwear to soak up any discharge from the wound.
A LIFT procedure involves a much smaller wound with the same type of care as above. A seton does not require much care other than regular washing and to avoid tugging on the suture or rubber tie.
