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Anal Abscess/Fistula

A patient who feels ill and complains of chills, fever and pain in the rectum or anus could be suffering from an anal abscess or fistula. These medical terms describe common ailments about which many people know little.

What is an Anal Abscess?


An anal abscess is an infected cavity, filled with pus, found near the anus or rectum.

What is an Anal Fistula?


An anal fistula, almost always the result of a previous abscess, is a small tunnel connecting the anal gland, from which the abscess arose, to the skin of the buttocks outside the anus.

What causes an Abscess?


An abscess results from an acute infection of a small gland just inside the anus, when bacteria or foreign matter enters the tissue through the gland. Certain conditions - colitis or other inflammation of the intestine, for example - can sometimes make these infections more likely.

What causes a Fistula?


After an abscess has been drained, a tunnel may persist connecting the anal gland from which the abscess arose to the skin. If this occurs, persistent drainage from the outside opening may indicate the persistence of this tunnel. If the outside opening of the tunnel heals, recurrent abscess may develop.

What are the Symptoms of an Abscess or Fistula?


Symptoms of both ailments include constant pain, sometimes accompanied by swelling, that is not necessarily related to bowel movements. Other symptoms include irritation of skin around the anus, drainage of pus (which often relieves the pain), fever, and feeling poorly in general.

Does an Abscess always become a Fistula?


A fistula develops in about 50 percent of all abscess cases and there is really no way to predict if this will occur.

How is an Abscess Treated?


An abscess is treated by draining the pus from the infected cavity, making an opening in the skin near the anus to relieve the pressure. Often, this can be done in the doctor's office using a local anesthetic. A large or deep abscess may require hospitalization and use of a different anesthetic method. Hospitalization may also be necessary for patients prone to more serious infections, such as diabetics or people with decreased immunity. Antibiotics are not usually an alternative to draining the pus because antibiotics are carried by the blood stream and do not penetrate the fluid within an abscess.

What about Treatment for a Fistula?

Surgery is necessary to cure an anal fistula. Although fistula surgery is usually relatively straightforward, the potential for complication still exists and should be performed by a specialist in colon and rectal surgery. It may be performed at the same time as the abscess surgery, although fistulae often develop four to six weeks after an abscess is drained sometimes even months or years later. Fistula surgery usually involves cutting a small portion of the anal sphincter muscle to open the tunnel, joining the external and internal opening and converting the tunnel into a groove that will then heal from within outward. Most of the time, fistula surgery can be performed on an outpatient basis - or with a short hospital stay.

How long does it take before patients feel better?


Discomfort after fistula surgery can be mild to moderate for the first week and can be controlled with pain pills. The amount of time lost from work or school is usually minimal. Treatment of an abscess or fistula is followed by a period of time at home, when soaking the affected area in warm water (sitz bath) is recommended three or four times a day. Stool softeners may also be recommended. It may be necessary to wear a gauze pad or mini-pad to prevent the drainage from soiling clothes. Bowel movements will not affect healing.

What are the chances of a Recurrence of an Abscess or Fistula?


If properly healed, the problem will usually not return. However, it is important to follow the directions of a colon and rectal surgeon to prevent recurrence

Perianal sepsis
Anatomy of anal canal
Internal sphincter = smooth muscle External sphincter = striated muscle Mucosa of upper third of anal canal no somatic sensation Mucosa of lower tow thirds of anal canal- somatic innervation from inferior rectal nerves Anal gland occur in intersphinteric plane & open at level of dentate line

Perianal & ischiorectal abscess

Probably arise from intersphinteric sepsis (Cryptoglandular Hypothesis) Abscesses classified as: o Perianal o Ischiorectal o Intersphinteric o Supralevator Initial surgery should simply be incision and drainage Avoid looking for fistula at initial surgery Rectal EUA at approximately five days Especially if gut related organisms on culture 80% recurrent abscesses associated with a fistula

Fistula-in-Ano
Goodsall's Rule = An external opening situated behind the transverse anal line will open into the anal canal in the midline posteriorly. An anterior opening is usually associated with a radial tract Fistulae may be classified as: o Intersphinteric (70%) o Transphinteric (25%) o Suprasphinteric (5%) o Extrasphinteric (<1%) Extrasphinteric fistulae are usually not associated with intersphinteric sepsis Consider inflammatory bowel disease or neoplasia

Investigation
Clinical assessment MRI Ultrasound

Picture provided by Richard Brouwer, St Vincent's Hospital, Melbourne, Australia

Treatment
Puborectalis is the key to future continence Low fistulas - Lay open with either fistulotomy or fistulectomy High fistulas - Require two stage surgery Setons - loose or tight Anorectal advancement flap may be considered

Picture provided by Kahlid Hameed, Aga Khan University Hospital, Karachi, Pakistan

Bibliography
Hughes F, Mehta S. Anorectal sepsis. Hosp Med 2002; 63: 166-169 McCourtney J S, Finlay I G. Setons in the surgical management of fistula-in-ano. Br J Surg 1995; 82: 448 - 452. Seow-Choen F, Nicholls R J. Anal Fistula. Br J Surg 1992; 79: 197 - 205. Thomas P. Decision making in surgery; acute anorectal sepsis. Br J Hosp Med 1993; 50: 204 - 205.

Figure 3. Surgical approach to perianal abscess drainage. A. Simple incision and drainage procedure for an abscess. B. Incision and drainage followed by placement of a mushroom drainage catheter for an abscess. Copyright 2000, Mayo Clinic.

Causes, incidence, and risk factors:


Infection of an anal fissure (cleft or slit), sexually transmitted infections, and blocked anal glands are causes of anorectal abscesses. Abscesses may occur in an area that is easily accessible for drainage, or higher in the rectum. Deep rectal abscesses may be caused by intestinal disorders such as Crohn's disease or diverticulitis. Superficial perianal abscesses are not uncommon in infants and toddlers who are still in diapers and have a history of anal fissures. The abscess often appears as a swollen, red, tender lump at the edge of the anus. The infant may be fussy from discomfort but there are generally no other associated systemic symptoms. Surgical drainage and antibiotics provide prompt relief.

Symptoms:
discharge of pus from the rectum lump or nodule, swollen, red, tender at edge of anus fever pain in or around the anal opening pain associated with bowel movements constipation (may occur)

Signs and tests:

A rectal examination may confirm the presence of an anorectal abscess. A proctosigmoidoscopy may be performed.

Treatment:
Abscesses are lanced and drained. Depending on the location of the abscess, the procedure may take place in an outpatient setting. If the abscess is very deep, surgery may be indicated. Warm sitz baths may assist with localization of the abscess to permit drainage. Pain medication and antibiotics may be indicated.

Expectations (prognosis):
The probable outcome is good with treatment. Infants and toddlers recover very quickly.

Complications:
systemic infection anal fistula formation

Calling your health care provider:


Call your health care provider if rectal discharge or other symptoms of anorectal abscess develop. Call your health care provider if fever, chills, or other new symptoms develop after treatment of an anorectal abscess. Prevention: In adults and adolescents prompt treatment or prevention of sexually transmitted diseases may prevent this cause of anorectal abscesses. Frequent diaper changes and attention to hygiene and cleansing at diaper changes will help prevent both anal fissures and perianal abscesses in infants and toddlers.