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An anorectal fistula is an abnormal tunnel or channel in the anal canal (narrow cavity extending from the rectum, where bowel movements occur). Often associated with infection, a fistula generally burrows from some point within the anal canal to the outside anal opening (sphincter). While multiple fistulae may occur, one typically is the norm.
In most cases, an anorectal fistula results from an abscess in the anal wall that discharges pus both into the anus and out onto the surrounding skin. Left untreated, an anorectal fistula can lead to inability to control bowel movements (fecal incontinence). Surgical intervention usually is required to resolve ongoing drainage of pus, fecal matter and/or blood.
Anorectal fistulae can develop from inflammatory bowel disease (Crohn's disease or ulcerative colitis), anal fissures, inflamed growths on the intestinal wall (diverticulitis), physical trauma to the anal region resulting from a surgical drainage procedure, puncture wound, injection treatment for hemorrhoids or injury from an enema tip, cancer in the anal region, radiation therapy, and sexually transmitted diseases (chlamydia, syphilis or gonorrhea). Other causes can include cancer of blood forming cells in bone marrow (leukemia), bacteria typically found in the lungs (tuberculosis), or chronic infection from Actinomyces israelii bacteria (Actinomycosis).
In about 90% of cases, however, anorectal fistulae cannot be linked to a specific cause (Gopal).
Incidence and Prevalence: Anorectal fistulae occur in 8.6 individuals per 100,000 population (Gopal). |
Source: Medical Disability Advisor
| Diagnosis occurs at an average age of 38 years (Gopal). Males are more likely to develop the condition. Women may develop a fistula between the rectum and the vagina, known as a rectovaginal fistula. Individuals with acquired immune deficiency syndrome (AIDS) have a 30% chance of developing fistulae and abscesses (Legall). |
Source: Medical Disability Advisor
History: Individuals with anorectal fistula usually complain of drainage or discharge of pus (purulent), blood and/or fecal matter from the external opening onto the skin around the anus. Irritation, itching, tenderness, or pain during or after bowel movements may also be reported. Physical exam: A lighted instrument may need to be inserted into the anus for close examination (anoscopy). One or more external (secondary) openings on the skin around the anus (perianal) appear as raised, reddish skin lesions (papules) less than 1 cm in diameter. If they are open (patent), the external opening(s) may express a drop of pus upon manipulation with a gloved finger (palpation). Alternatively, the openings may be naturally sealed. The channel may feel like a hardened, long, rounded structure (indurated cord). Examination with a gloved finger (digital rectal exam) can help determine how the channel lies within the tissue. Tests: Examination of the rectum (sigmoidoscopy) using a flexible, fiber-optic viewing instrument is required to locate the internal (primary) opening of the fistula channel. If the primary opening is sealed, secondary openings may be found along the fistula's internal channel. Injecting a contrast medium such as barium into the rectum and taking x-rays may also help identify openings. X-rays of the upper gastrointestinal tract following ingestion of a white pigmented substance (radiopaque contrast medium, upper gastrointestinal series), sectional x-rays (computed tomography or CT), and high-frequency sound waves (ultrasonography) may be required for imaging boundaries of the fistula in certain complex situations.
To rule out underlying conditions such as sexually transmitted diseases, laboratory tests may be needed, including an investigation of blood cells and platelets (complete blood count, or CBC) and analysis of white blood cells (WBC) for presence of infection. |
Source: Medical Disability Advisor
| Minor surgery (fistulectomy or fistulotomy) under local anesthesia usually is required for anorectal fistulae, which rarely heal spontaneously. Occasionally, a general anesthetic is needed for more complex cases. During fistulectomy, the channel is opened, the fistulous lining removed, and the abscess drained. During fistulotomy, the entire channel is completely cut open and allowed to heal. In either case, broad-spectrum antibiotics may be prescribed before and after surgery. In complicated or recurrent cases, a new technique involves patching the area with a type of adhesive derived from human blood plasma (autologous fibrin glue). After surgery, management consists of warm sitz baths, frequent wound inspection, and attention to stool consistency. Stool softeners may aid in preventing constipation. |
Source: Medical Disability Advisor
Some fistulae may recur because of internal openings that were missed during initial treatment. Uncomplicated fistulae that are not accompanied by conditions such as inflammatory bowel disease are likely to be resolved. In certain complicated cases, surgical success rates range from 68% to 75% with accompanying risk of at least 10% for developing fecal incontinence as a side effect. One study reported at least a 60% cure rate for individuals undergoing autologous fibrin glue treatments in complicated cases of anorectal fistulae (Hull).
Following surgery, healing of an anorectal fistula proceeds without complications in the vast majority of cases. In individuals with more complicated fistulae, extensive surgical treatment may interfere with the ability to control defecation (continence) and lead to additional rectal surgery. Individuals with Crohn's disease, ulcerative colitis, diabetes, AIDS, chronic diarrhea, or other underlying conditions may experience recurring fistulas or wounds that heal improperly. |
Source: Medical Disability Advisor
| To help the wound to heal properly and to relieve discomfort, the use of stool softeners and frequent sitz baths are helpful. Close follow-up and careful nursing of the wound by a physician/nurse team may be necessary to assist with dressing changes and monitor progress after surgery for complex fistulas. |
Source: Medical Disability Advisor
Skin bridges may enclose an area within the channel and allow an infected area (abscess) to develop. Untreated fistulas may cause systemic infection. Rare examples of cancer (carcinoma) arising in anorectal fistulas have been reported.
Minor degrees of soiling or incontinence may occur after surgical treatment of a fistula. |
Source: Medical Disability Advisor
| If the individual has had surgical treatment, time off from work to recover from surgery is needed. If sedentary duties are available, the individual may return to work during the latter weeks of recovery, but lifting and climbing activities may not be permitted until postoperative recovery is complete. Frequent breaks to avoid prolonged sitting and close access to bathroom facilities may also be necessary until full recovery is achieved. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual have inflammatory bowel disease or anal fissures?
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Was there hemorrhoid treatment or physical trauma to the anal region?
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Has individual had cancer or radiation treatment in the anal area?
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Is there a history of chlamydial infections?
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Was there an injury from an enema tip?
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Does individual complain of purulent drainage around the anus? Does itching, tenderness, or pain occur after a bowel movement?
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Did the physician find openings on the skin around the anus? Was pus expressed? During a digital exam, was the channel palpable?
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Were anoscopy, sigmoidoscopy, or barium enema done? Were upper GI series, CT, and ultrasound performed?
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Were conditions with similar symptoms ruled out?
Regarding treatment:
- Did individual have surgery?
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Were broad-spectrum antibiotics prescribed before and after surgery?
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Is individual compliant with warm sitz baths and frequent wound inspection?
Regarding prognosis:
- Does individual have continence problems?
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Does individual have any conditions that may affect recovery?
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Has individual had recurrent fistulas?
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Can individual's employer accommodate restrictions?
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Source: Medical Disability Advisor
| CitedGopal, D. V. "Diseases of the Rectum and Anus: A Clinical Approach to Common Disorders." Clinical Cornerstone 4 4 (2002): 34-48.Hull, Tracy. "Anorectal Fistula-in-Ano." Sleisenger & Fordtran’s Gastrointestinal and Liver Disease (2003): Legall, Ingrid. "Anal Fistulas and Fissures." eMedicine. Eds. Michael S. Beeson, et al. 11 Jun. 2001. Medscape. 13 Sep. 2004 <http://emedicine.com/emerg/topic495.htm>. |
Source: Medical Disability Advisor
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