Anal Fistula Can Be Difficult To Treat

This model illustrates various pathology of the rectum. (iStockphoto/Thinkstock)
This model illustrates various pathology of the rectum. (iStockphoto/Thinkstock)

Last week, I was in San Francisco, California to attend the Clinical Congress (convention) organized by the American College of Surgeons. It is one of the largest surgical conventions in the world. The convention lasts five days (Sunday to Thursday). By Wednesday afternoon, total registration for the convention was 14,397: 8916 were physicians and the rest were exhibitors, guests, spouses and convention personnel.

Not everybody is in one auditorium or room at the same time. Each room has its own list of speakers and topics for discussion. So you head yourself to a room which offers discussion on a topic which interests you the most. The conference was held at the Moscone Convention Center. It is the largest convention and exhibition complex in

San Francisco. It comprises three main halls with total of 84,000 square meters of space (900,000 square feet).

One of the symposiums I attended was on surgical problems of anus and rectum: cancer, fistula, fissure and hemorrhoids. Today, I will review the subject of anal fistula (fistula-in-ano).

What is a fistula? A fistula is an abnormal tunnel connecting two body cavities (such as the rectum and the vagina) or a body cavity to the skin (like the rectum to the outside of the body). Fistulas are usually the result of infection, injury or surgery. With an anal fistula there is a tunnel between the anus (and/or rectum) to the skin. A peri-anal abscess has a 50 per cent risk of turning into a fistula.

Anal fistulas do not generally harm the body. They are mainly a nuisance with some pain or discomfort and irritating intermittent discharge of blood, pus or stool. They can form recurrent abscesses which may require drainage under local anaesthetic.

Most of the time the diagnosis of fistula is made on the basis of classical clinical history and physical findings. Examination of the rectum may show an opening of the fistula onto the skin, the area may be painful on examination, there may be redness, a discharge may be seen or it may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula.

Treatment of the fistula depends on the presentation of the problem. If there is active infection or abscess then it needs to be treated with drainage of the pus and antibiotics. Once the infection is cleared the fistula can be treated surgically. If it is difficult to get rid of the infection then long term drainage can be established by inserting a seton – a length of suture material or thin rubber tubing is looped through the fistula which keeps it open and allows pus to drain out.

The treatment aim should be to prevent recurrence of fistula. Treatment depends on where the fistula lies, and which parts of the anal sphincter it crosses.

There are several options. Doing nothing – a drainage seton can be left in place long-term to prevent problems. But this does not cure the fistula. Fistula can be layed open under anaesthetic. Once the fistula has been layed open it will be packed on a daily basis for a short period of time to ensure that the wound heals from the inside out. Depending on the depth of the fistula, this option may affect continence if the fistula involves sphincter muscles. Most fistulas are superficial and can be layed open under local anaesthetic without much problem with continence.

Other methods of treating fistula are: using fibrin glue injection, using fistula plug, creating a flap to cover the internal fistula opening and using a seton to cut through the deep fistulous tract. Each method has advantages and disadvantages.

Some fistulas are very difficult to treat if they are caused by inflammatory bowel disease like Crohn’s disease. Any patient with recurrent fistula should be investigated for inflammatory bowel disease. Otherwise, most fistulas can be cured with patience and perseverance.

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11 Replies to “Anal Fistula Can Be Difficult To Treat”

  1. “…most fistulas can be cured with patience and perseverance.”

    Look up a couple of the on-line forums for fistula sufferers and you’ll find an entirely different picture. One third of all flap surgeries fail and many — even those that cure the fistula — lead to a lifetime of incontenence. Fistula plugs are relatively painless (I’ve had three), but fail at a high rate. There is no fistula surgery that has a high rate of success. Invent one and you’ll be rich.

    Second, you would have a hard time convincing me that perianal fistulas “do not generally harm the body.” I’ve had 13 surgeries and been on antibiotics and pain killers for more than three years because of a perianal fistula. I’ve had one infection after another. My life has come to a screeching halt while we deal with this problem. What I’m dealing with is common.

    What bothers me the most is any downplaying of the seriousness of the condition. My health has suffered, as has my wallet, because a general surgeon did not treat me properly for the first year. This surgeon, in fact, told me to be patient and wait for the fistula to heal. A fistula can’t heal as long as the rectum continues to supply fecal matter, which is the source of infection that leads from rectum, through fistula, to abscess (pocket or pockets of infection).

    Perianal fistulas, especially when made worse through neglect, create serious health risks. In my opinion, this is a problem best left for colorectal surgeons who have had specialized training and a great deal of experience.

    1. Hi,

      After reading the previous comment I can understand how much you have suffered. I am neither a doctor nor a fistula patient who has recovered from the dreaded disease. Can only empathise with your condition. But will suggest you to try opting for “Ksharasutra” treatment of Fistula. For more information, you may search the Internet. Hope it helps to get rid of this.

  2. CHS –

    I don’t know if anyone else will happen to read this but I will respond anyway.

    I couldn’t agree more with you! and am sorry that you have suffered with this awful affliction.

    The infection from the fistula totally destroys my well being. Terrible fatigue, low grade fever and nausea. The antibiotics only work for a short time until reinfection occurs. The only thing that has helped me is using an antibiotic ointment to massage into the rectum.

    The news here is that I believe that the fistula was actually caused by parasites. Pin worms can burrow through flesh and may cause an infection that leads to an abscess. I can actually feel the worms crawling out of the fistula opening.

    I had no symptoms of pin worms and was totally unaware that I had them until very recently.

    If this is the case with some if not many fistula sufferers, it’s no wonder that surgeries often fail with a parasite continuously reinfecting the fistula.

    1. Omg I feel the extact same caused mine but when I’ve mentioned it to drs they look at me like I’m alien lol, started last yr in Egypt I’ve had 3 surgeries since, and still none the wiser about what’s going on! I have to get all my info offline which I think is a disgrace as the drs or surgeon can’t even answer my questions, how did you find out it was parasites After?


  4. hi
    i have fistula after an abcess surgery.and i am taking antibiotic sepcen(syprofloxacine) for 3 weeks. can i continue it to heal the fistula?is it danger to continue the antibiotic with out surgery?

  5. Sir I have anal fistula..I went to doctor..he gave some ointment and it is cured..but now it came again..but two of them in the same place..wat to do..I am having it for more than a year…is it dangerous…plz help

  6. I have undergone fistula operation two times and my biopsy came normal but even after two years of operation also the wound made for discharging is not healing and I get regularly puss and blood is saying it is not fistula and may not be a IBD .then what it must be ? If any one knows please answer it

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