ANAL

FISTULA
NTRODUCTI
ON

An anal fistula is a tiny, tubular, fibrous tract

that extends into the anal canal from an
opening located beside the anus in the
perianal skin. Fistulas usually result from an
abscess. They may also develop from
trauma, fissures, or Crohn’s disease.
Purulent drainage or stool may leak
constantly from the cutaneous opening.

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Types of
Fistula
Parks classification system
The classification system developed by Parks, Gordon, and Hardcastle (generally
known as the Parks classification) is the one most commonly used for fistula-in-ano.
This system defines four types of fistula-in-ano that result from cryptoglandular
infections, as follows:

Intersphincteric- It is the result of a perianal abscess

Trans sphincteric-In its usual variety, this fistula results from an ischiorectal
fossa abscess
Suprasphincteric-It arises from a supralevator abscess
Extrasphincteric-It may arise from foreign body penetration of the rectum with
drainage through the levators, from penetrating injury to the perineum, from
Crohn disease or carcinoma or its treatment, or from pelvic inflammatory disease.

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 Epidemiolo
gy

One study showed that the prevalence of fistula-in-ano is 8.6

cases per 100,00The true prevalence of fistula-in-ano is unknown.
The incidence of a fistula-in-ano developing from an anal abscess
range from 26% to 38%. 0 population.

One study showed

. In men, the
that the prevalence of in women, it is 5.6
prevalence is 12.3
fistula-in-ano is 8.6 cases per 100,000
cases per 100,000
cases per 100,000 population
population,
population

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 Causes/
Etiology
In the vast majority of cases, fistula-in-ano is
caused by a previous anorectal abscess.
Typically, there are eight to 10 anal crypt glands at
the level of the dentate line in the anal canal,
arranged circumferentially. These glands penetrate
the internal sphincter and end in the
intersphincteric plane. They provide a path by
ANAL
which infecting organisms can reach the
FISTULA
intramuscular spaces. The cryptoglandular
hypothesis states that an infection begins in the
anal canal glands and progresses into the muscular
wall of the anal sphincters to cause an anorectal
abscess. 7
Risk Factors Anal fistulas are more common in men. However, women also
get them. They are also more common in those 30 to 50 years
old. Other things that may raise the risk are:

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 Signs and
Symptoms

● Frequent anal abscesses

● Pain and swelling around the anus
● Bloody or foul-smelling drainage (pus) from
an opening around the anus. The pain may
decrease after the fistula drains.
● Irritation of the skin around the anus from
drainage
● Pain with bowel movements
● Bleeding
● Fever, chills and a general feeling of fatigue
Pathophysiolog
y
Anal fistula develops from
infection of anal crypts glands.

The initial infection occurs in the

If the abscess is ruptured,
5 2 ducts of the anal glands and the
The fistula is formed
spread of infection results in the
formation of the abscess

The presence of these glands deep in relation to the The cryptoglandular theory states
anal canal and sphincter,the infection alows the 4 3 that obstruction of anal gland
path of the least resistance resulting in abscess duct results in an infection
formation at the termination of the gland

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Laboratory and Diagnostic
Test

Anoscopy Probe Fistulography

CT Scan & MRI
Exam of the anal A thin, small probe is inserted an x-ray to look at the fistula
canal with a scope into the anal skin to see if a
channel is present

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Medication
s

Medications may also be prescribed for anal fissures, such as

● Topical nitrates
● calcium channel blockers
● onabotulinumtoxinA injections and are considered first-line
therapy.

These medications reduce anal sphincter tone, which, in turn,

increases anodermal blood flow.

Antibiotics may be necessary for the treatment of anal fistulas,

especially if the patient presents with systemic symptoms.
Postoperative prophylactic antibiotic therapy for 7-10 days (e.g.,
ciprofloxacin, metronidazole) appears to be a key part of
preventing anal fistulas after incision and drainage of perianal
abscess.

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 Surgical
Management

Fistulotomy

- A fistulotomy is a surgical procedure for treating a

fistula in the anal area. An anal fistula is a small
opening or tunnel that develops between the anal skin
and the end of the anus. The causes of an anal fistula
include injury, severe inflammation, infection, and pus
collection in the area

Fistulectomy

- Fistulectomy is a surgical procedure where a

fistulous tract is excised (cut out) completely.

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Seton Technique
A seton is a piece of surgical thread that's left in
the fistula for several weeks to keep it open.

Endorrectal Flap
- A flap is created to expose the internal opening
of the fistula. The fistula is stitched shut and the
flap is put back in place

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Medical
Management

Preoperative considerations

● Rectal irrigation with enemas should be performed on the morning of

the operation
● Anesthesia can be general, local with intravenous sedation, or a
regional block
● Administer preoperative antibiotics
● The prone jackknife position with buttocks apart is the most
advantageous position

Intraoperative considerations

● Examine the patient under anesthesia to confirm the extent of the

fistula
● Identifying the internal opening to prevent recurrence is imperative
● A local anesthetic block at the end of the procedure provides
postoperative analgesia
Nursing Management
● Encourage the patient to urinate, but avoid catheterization and the use of suppositories. Postoperatively, a bulk laxative
or stool softener is often prescribed on the day of the surgery.
● Assess the perirectal area hourly for bleeding for the first 12 to 24 hours postoperatively. When open fistula wounds are
left, as in a fistulotomy, the anal canal may be packed lightly with oxidized cellulose.
● Encourage the patient to drink clear liquids after any nausea has passed. Once clear liquids have been taken without
nausea or vomiting, remove the intravenous fluids, and encourage the patient to begin to drink a full liquid diet the day
after surgery. From there, the patient can progress to a regular diet by the third day after surgery.
● Immediately following the procedure and before the patient enters the post anesthesia care unit, place a dry, sterile
dressing on the surgical site.
● Provide sitz baths twice a day for comfort and cleanliness, and place a plastic inflatable doughnut on a chair or bed to
ease the pain of sitting.
● As soon as the patient tolerates activity, encourage ambulation to limit postoperative complications
● Teach the patient how to keep the perianal area clean; teach the female patient to wipe the perineal area from front-to-
back after a bowel movement in order to prevent genitourinary infection.
● Teach the patient about the need for a high-fiber diet that helps prevent hard stools and constipation.
● Explain how constipation can lead to straining that increases pressure at the incision site. Unless the patient is on fluid
restriction, encourage him or her to drink at least 3 L of fluid a day.
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Discharge Plan
● Teach the patient to avoid using bar soap directly on the anus because it can cause irritation to the
anal tissue.
● Teach patients to dilute the soap with water on a washcloth to cleanse the area.
● Explain the need to remain on a diet that will not cause physical trauma or irritation to the perirectal
area.
● mphasize to the patient the need to avoid spicy foods and hot peppers to decrease irritation to the
perirectal area upon defecation.
● Teach the patient the purpose, dosage, schedule, precautions and potential side effects, interactions,
and adverse reactions of all prescribed medications.
● Encourage the patient to complete the entire prescription of antibiotics that are prescribed.

Prevention
● The risk of anal fistula may be lowered by Carefully cleaning and treating anal/rectal wounds
● Managing certain health conditions 1
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THANKS

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