You are on page 1of 4

PERIANAL FISTULAS / ANAL FARUNCULOSIS; A MEDICAL DISEASE THAT SOMETIMES

NEEDS SURGERY
Gary W. Ellison, DVM, MS, Diplomate ACVS
University of Florida, College of Veterinary Medicine, Gainesville, FL
Perianal fistulas (US) or anal furunculosis (GB) represents a demanding medical and surgical
problem of the anal region. Synonyms include perianal sinuses, perianal fistulae, perianal fissures,
furunculosis, perirectal fistulae, anusitis and fistulae-in-ano. German Shepherds and Irish Setters are breeds
at increased risk, but the condition is also reported in sheepdogs, retrievers and spaniels. The condition is
seen primarily in middle aged dogs with a mean age of seven and an age range of two to 12. Males are
affected in about 65% of the cases. Common clinical signs are painful defecation, bloody defecation,
ulcerated malodorous perianal region, low tail carriage and weight loss or lethargy.
ETIOPATHOGENESIS
The etiopathogenesis of perianal fistulas is still unresolved. One hypothesis is that low tail
carriage allows moisture and bacteria from feces, rectal mucus, or anal sac secretions to accumulate in the
perianal region with resultant inflammation and infection of the anal skin and adnexa. The macroscopic and
microscopic anatomy of the anocutaneous zone of German Shepherds is similar to that of dogs of other
breeds except for an increased density of perianal apocrine sweat glands in German Shepherds. However, it
is unclear whether these sweat glands truly have any role in the development of perianal fistulas. It has
been postulated that hypothyroidism or immunodeficiency syndromes may predispose German Shepherds
to perianal fistulas, but in one study, neither thyroid stimulation test results nor serum IgA concentrations
were significantly different in diseased vs clinically normal dogs. Other proposed etiologies of the fistulas
include: 1) impaction and infection of the anal sinuses or anal crypts (as seen in man), 2) inflammation and
necrosis of the apocrine glands (Hidradenitis supporitiva), 3) infection of circumanal glands or hair follicles
(folliculitis), 4) anal sac infection or abscessation, and 5) hypothyroidism. In a study of the 106 dogs with
perianal fistulae, 52 dogs had hidradenitis or folliculitis, 30 had fistulae of the anal sinuses, 66 had ruptured
anal sacs and 30 had submucosal fistulae in the rectum or various combinations of the above.
In recent years anal furunculosis research has focused on an immune mediated inflammatory
bowel disease and ulcerative perianal dermatitis similar to Crohns disease in man. Infiltration of the
circumanal glands with immunocytes has been seen. This is a plausible explanation since responsiveness to
immunosuppressive therapy has been good to excellent in many dogs.
LOCAL HYGIENE
Removal of all perianal hair and twice daily cleansing of the perianal region with a 1% solution of
povidone iodine or a 0.5% solution of chlorhexidine gluconate may be useful in reducing suppurative
inflammation but will not institute a cure. Simultaneous elevation of the tail with a side brace made from
aluminum rods may allow for better aeration of the perianal region and may result in healing of superficial
ulcerations. Although short term topical or systemic antibiotic therapy may help reduce the effects of
secondary bacterial infection long term administration of antibiotics is of questionable value, because
bacteria are not the primary cause of perianal fistulas.
MEDICAL THERAPY
Medical treatment of perianal fistulas should be attempted prior to surgical treatment. Several
successful medical therapies have been described for treatment of perianal fistulas.
Prednisone and Fish and Potato Diet: With this therapy dogs with coexisting inflammatory
bowel disease and perianal fistulas can be treated with high doses of prednisone (2 mg/kg SID for two
weeks followed by 1mg/kg for an additional four weeks) plus a fish and potato diet for a period of 6 weeks.
With this protocol approximately 1/3 of the cases completely resolve, 1/3 improve but dont clear and 1/3
show no improvement. The treatment is not expensive but side effects are high. Nine of 30 German
shepherds with inflammatory bowel disease had coexisting perianal fistulas completely resolve after this
treatment. Eleven dogs had improvement in the severity of their fistulas while 10 of the dogs had no
improvement after prednisolone therapy. Further long term studies are necessary to determine the efficacy
of this treatment. The dogs develop signs of Cushings disease and PU/PD is noted by owners. Accidents in
the house are common.
Cyclosporin. This is the new state-of-the-art treatment for perianal fistulas. A powerful

immunosuppressive agent which causes minimal side effects this drug suppresses t helper cell function
When given doses of 2-3 mg/kg BID of cyclosporine A for 12 weeks virtually all dogs show improvement
and 50-60% clear completely. Unfortunately 40-50% of the patients still require surgery because of
inadequate resolution of their fistulas. Most dogs that dont resolve or recur have anal sac disease and the
anal sacs must be removed. Also the treatment is very expensive costing $1200-$1500. The main side effect
is excessive shedding. Renal and liver failure is possible but rare.
The cyclosporine preparation is available in 25 50 and 100mg gelcaps Neoral (Sandoz/Novartis) or
Neoral liquid preparation 100mg/ml. It is given twice daily with food. Alternatively you can give
ketaconazole 10mg/Kg (a competitive binder of the 450 hepatic enzyme) with .25-.5mg/KG of
cyclosporine SID. This saves about 35% on the cost but requires closer monitoring of liver values since
hepatic necrosis is much more likely. Therapy should be for continued for 12 weeks or two weeks after
resolution of lesions.
Absorption is of Cyclosporine is highly variable between dogs and it is it is preferable to send a 12
hour (BID) or 24 hour(SID)blood sample to a lab which assays blood trough CSA levels. The sample is
submitted approximately one week after initiation of therapy. Keeping levels between 200-400 ng/ml will
ensure that adequate therapeutic levels are achieved and renal toxicity is reduced.
Topical Tacrolimus
Tacrolimus is an immunosuppressive drug with similar activity to
Cyclosporine. The drug is more expensive than cyclosporin for oral use but for is has been used topically as
a treatment for anal furunculosis. The advantage of such preparations includes greatly reduced costs and
less chance for toxicity. To date the treatment has been reported in only 10 dogs with a 50% resolution rate
and 90% improvement rate. Further clinical studies are warranted.
Azathioprine and Metronidazole This combination of a powerful but immunosuppressive drug and
an anti anaerobe antibiotic has been helpful in reducing lesion size prior to surgery but has not had the
success rates of other remedies. The azathioprine is given at 50mg SID and the Metronidazole at 400mg
SID for period of up to 6 weeks.
SURGICAL TREATMENT
Successful management of perianal fistulas should be defined as surgical control because it is
doubtful that a true cure exists in many cases. A rectal examination is performed under deep sedation or
general anesthesia to determine, 1) how much of the circumference is involved, 2) if there is deep anal
sphincter involvement or stricture formation, and 3) how far the tracts extend peripherally. The fecal
contents are evacuated digitally and soapy water enemas are administered the evening before surgery. Some
surgeons will culture the fistulous tracts and start the animal on a regimen of antibiotics prior to beginning
the procedure.
Surgical excision, with anal sacculectomy has been a preferred procedure by many surgeons for
moderate to severe cases of perianal fistula. Limitations of excision include 1) the inability to excise all of
the tracts if they extend too far peripherally and 2) danger of creating incontinence if the tracts deeply
invade the external anal sphincter. If rectal or anal strictures are present due to deep seated invasion of the
external anal sphincter by the fistulas then excision of the areas of fibrosis must be attempted for clinical
signs to be relieved. Once anal sacculectomy is performed, a circular incision is made around the periphery
of the fistulas. A plane is established deep to the fistulas and dissection is carried medially toward the anal
canal. Care must be taken to stay as close to the fistulas as possible to preserve external anal sphincter but it
is important to dissect deep to the fibrous tracts. Hemorrhage is moderate and is controlled with
electrocoagulation. The dissection is carried medially to the anal canal and a circular incision is made in
healthy rectal mucosa cranial to any rectal or anal sinuses. Eight to ten simple interrupted sutures of 2-0
synthetic absorbable suture are used to appose the rectal submucosa to the subcutis. The rectal mucosa is
then sutured to the skin with a simple interrupted 3-0 monofilament nylon or prolene sutures. Often there
are areas where the fistulas extend so far peripherally that direct skin to mucosal apposition is not possible.
In these cases the adjacent areas of skin can be apposed or the area can be left open to heal by granulation. Fecal incontinence is often less of a problem with first time procedures, but has occurred more commonly
when other procedures have been performed previously. The long term success rate reported varies from 46
to 85%. Reexaminations every two months are necessary to look for early signs of recurrence.
Deroofing and fulguration is a relatively non-invasive technique that has proved successful in
cases where fistulas are not extensive and are located relatively superficially. A bilateral anal sacculectomy

is performed initially. The tracts are then probed and opened using a groove director, scissors or an
electroscalpel. The lesions are fully explored and all chronic granulation tissue or scar tissue is excised
from the "roof" of the tract creating a saucer shaped wound. No attempt is made to dissect the base of the
lesions or deeper structures. The lining of the cavity is then electrofulgurated using a low sparkgap current
with the electroscalpel held 3-4 mm from the tissue. This eliminates thermal destruction of the deeper
external anal sphincter. An alternative for units not equipped with sparkgap current is to use a ball tip
electrode probe with a coagulation current. The wounds are left open to heal by second intention.
Postoperative care involves BID cleansing of the area and frequent followups are paramount to success.
Wounds sometimes will not close completely for 3-4 weeks. The most common sequelae to deroofing and
fulguration in cases of external fistulas is the persistence of tracts and the development of anal strictures.
Animals often have to be operated more than once and anoplasty is sometimes required to correct stenosis.
Cryosurgery has been described as treatment for perianal fistulas. Cryonecrosis of the fistulous
tracts is followed by sloughing of the diseased tissue and healing by second intention. Recurrence rates
after cryotherapy of perianal fistulas have been superior to some other methods of therapy. Unfortunately,
cryonecrosis is not selective for the fistulas only and deep scarring with resultant anal stenosis is a common
sequela. A second procedure requiring resection of the stricture and anoplasty is required in about 50% of
these cases.
Caudectomy or high tail amputation is advocated by some surgeons as a means of eliminating
fecal soiling of the perianal area. In order to be effective the amputation must include the lateral skin folds
of the tail up to the second or third coccygeal vertebra. Caudectomy alone causes improvement of perianal
fistulas in a high percent of the cases, but complete resolution of the deeper fistulas usual does not occur.
Our experience in a limited number of cases receiving caudectomy alone is that the progression of the
disease is halted and some of the superficial tracts dry up but the deeper indurated areas of fibrosis or
stricture do not always resolve. Our initial impression is that caudectomy in conjunction with excision of
the fistulas may be a viable method for completely eradicating the disease in some dogs.
Laser excision - Results using a Nd/YAG contact-tip laser to treat perianal fistulas have recently
been reported. A frosted, synthetic sapphire tip and a continuous impulse of 13 to 15 watts was used to
excise the fistulas, and the wound was closed primarily. Fecal tone was reduced and flatulence was
increased in 60% of the dogs and 20% of the dogs developed fecal incontinence. However, fecal
incontinence was effectively managed by means of diet modification. Overall success rate for the 20 dogs
that were treated was 95% over a mean follow-up time of 22.9 months. The treatment was particularly
effective relieving pain in those dogs with pre-existing anal stenosis.
POSTOPERATIVE CARE AND PROGNOSIS
Regardless of the surgical technique good local perianal hygiene must be provided by the owner.
Periodic clipping of the perianal region is mandatory. Owners are advised to flush the area with dilute
povidone iodine .1% or chlorhexidine acetate .5% for BID until the wounds are closed. Thereafter BID
hoseflushing under the tail is recommended if weather permits. Incontinence when present can usually be
managed by direct modification by feeding a more highly digestible kibbled food. With excision techniques
new small developing fistulas as managed with either chemical silver nitrate cautery, deroofing and
fulguration or resection of the new fistulas.
Prognosis is guarded in all cases of perianal fistulas. I have personally had the best results with
sharp or laser excision techniques but risk of incontinence is high when the fistulas are deep. Deroofing and
fulguration is of questionable value when the fistulas extend > 90% around the circumference of the anus.
Cryotherapy has fallen out of favor because of postoperative stricture formation in most cases. Caudectomy
has not proved to be the cure all as once promised but seems to be a valuable ancillary technique that keep
fistulas from progressing and is especially suited for unmanageable dogs.
REFERENCES
1. Johnston DE. Surgical diseases of the rectum and anus. In: Textbook of Small Animal Surgery, Slatter
(ed). Philadelphia, WB Saunders, 1985.
2. Goring RR, Bright RM, Stoncil ML. Perianal fistulas in the dog. Retrospective evaluation of surgical
treatment by deroofing and fulguration. Vet Surg 1986;15:392.

3.

van Ee RT, Palminteri A. Tail amputation for treatment of perianal fistulas in dogs. J Am Anim Hosp
Assoc 1987;23:95.
4. Killingsworth CR, Walshaw R, Reimann KA, Rosser EJ. Thyroid and immunologic status of dogs with
perianal fistula. Am J Vet Res 1988;49:1742-1746.
5. Matushek KJ, Rosin E. Perianal fistulas in dogs. Comp Cont Ed Sm Anim Pract 1991; 13:621-627.
6. Ellison GW, Bellah JR, Stubbs WP. Treatment of perianal fistulas with ND/YAG laser - Results of 20
cases. Vet Surg 1995;24:140-147.
7. Ellison GW. Treatment of perianal fistulas in dogs. J Am Vet Med Assoc 1995;206:1680-1683.
8. Mathews KA, Sukhiani HR. Randomized controlled trial of cyclosporine for treatment of perianal
fistulas in dogs. J Am Vet Med Assoc 1997;211:1249.
9. Messighers BS. Clinical observations of the treatment of canine perianal fistula with topical tacrolimus
in 10 dogs. Can Vet J. 2000;41:623.
10. Tisdall PLC, Management of perianal fistulae in five dogs using azothiaprine and metronidazole prior
to surgery. Aus Vet J 1999;77:374.