Fistula-in-Ano Etiology An anorectal fistula (Fistula-in-Ano) is an abnormal communication between the anus and the perianal

skin. Anal canal glands situated at the dentate line afford a path for infecting organisms to reach the intramuscular spaces. Fistulas can occur spontaneously or secondary to a perianal (or perirectal) abscess. In fact, following drainage of a perianal abscess, there is an approximate 50% chance of developing a chronic fistula. Other fistulae develop secondary to trauma, Crohn's disease, anal fissures, carcinoma, radiation therapy, actinomycoses, tuberculosis, and chlamydial infections. The cryptoglandular hypothesis states that an infection begins in the anal gland and progresses into the muscular wall of the anal sphincters to cause an anorectal abscess. Following surgical or spontaneous drainage in the perianal skin, occasionally a granulation tissue-lined tract is left behind, causing recurrent symptoms. Classification Fistulas are named according to the Park's Classification of Perianal Fistulas:
Transsphincteric fistulae are the result of ischiorectal abscesses, with extension of the tract through the external sphincter. Account for about 25% of all fistulae. Intersphincteric fistulae are confined to the intersphincteric space and internal sphincter. They result from perianal abscesses. Account for about 70% of all fistulae. Suprasphincteric fistulae are the result of supralevator abscesses. They pass through the levator ani muscle, over the top of the puborectalis muscle, and into the intersphincteric space. Account for about 5% of all fistulae. Extrasphincteric fistulae bypass the anal canal and sphincter mechanism, passing through the ischiorectal fossa and levator ani muscle, and open

that the further away the external opening is from the anus. or HIV infection may suggest a more complex fistula. Goodsall's Rule can be applied. and surgery to correct the problem is necessary. the less reliable Goodsall's rule becomes. swelling. the fistula usually curves to the posterior midline of the anal canal. however. thereby opening (or unroofing) the tract. the fistula usually runs directly into the anal canal. or excoriation at the tract site.high in the rectum. Discharge from the tract may be spontaneous or expressible with a digital rectal examination. In this procedure. Clinical Presentation Patients with Fistula-in-Ano present with chronic drainage of pus or stool from the skin opening. Physical exam remains the mainstay of diagnosis. Treatment The laying open technique (fistulotomy) is useful in the majority of fistulae repairs. With the patient in the lithotomy position: If the external opening is anterior to an imaginary line drawn horizontally through the anal canal. looking for an external opening that appears as an open sinus or elevation of granulation tissue. a probe is inserted through the fistula (through both openings). and sphincter muscle are divided. Accounts for about only 1% of all fistulae. the trajectory of a complex fistula is unpredictable. Anoscopy is usually required to identify the internal opening. Curettage is used to remove . Patients may also complain of pain. and the overlying skin. The physician should observe the entire perineum. If the external opening is posterior to the line. and probable location of the internal opening. subcutaneous tissue. It should be noted. diverticulitis. previous radiation therapy. Additionally. steroid therapy. The tracts do not heal on their own. Goodsall's Rule In order to help the examiner predict the trajectory of the tract. and a history of IBD.

The seton is tightened during repeat office visits until it is pulled through over 6-8 weeks. it gradually cuts through the sphincter muscle. with time. or in combination with a fistulotomy. As with most anorectal disorders.granulation tissue in the tract base. that is threaded through the fistula tract and serves three purposes. A seton is typically made from a large silk suture. recurrent fistulae. as fibrosis occurs above the seton. The fistulotomy is allowed to close by secondary intention. . Crohn's disease. analgesics for pain. follow-up care includes sitz baths. That is. The advantage of using a seton. and it also cuts through the fistula. is that this "staged fistulotomy" allows for progressive division of the sphincter muscle. stool bulking agents. or rubber band. avoiding the complication of incontinence. and exteriorizes the tract. and good perianal hygiene. silastic vessel marker. a seton can be used alone. or with poor preoperative sphincter pressures. immunocompromised states. In patients with complex fistulae. It allows direct visualization of the tract. it allows drainage and promotes fibrosis. Care is taken to avoid cutting too large a portion of the sphincter (which could lead to incontinence).