Anal fistulas are pathologically altered ducts (fistulas) in the perianal area, which in most cases can be traced back to a proctodeal infection with abscess formation. Surgical intervention or fistula splitting represents the primary therapeutic measure for anal fistulas.
What are anal fistulas?
Anal fistulas are pathologically altered ducts (fistulas) in the perianal area, which in most cases can be traced back to a proctodeal infection with abscess formation. An anal fistula (also fistula ani) is a pathologically altered, tubular connection between the external anal region (external fistula opening) and the anal canal or rectum (internal fistula opening). Anafistulas usually show inflammatory changes, which is why purulent secretion is discharged through the fistula canal, which may be mixed with stool. Depending on the anatomical location and its course, a distinction is made between intersphincteric (located between the two anal sphincters), extrasphincteric (surrounding the sphincter apparatus), submucosal (located between the rectal mucosa and the internal anal sphincter), transsphincteric (crossing both anal sphincters), subcutaneous, and suprasphincteric (running between the sphincter and the pelvic floor muscle) anal fistulas.
Causes
In most cases, anal fistulas can be attributed to minor anal abscesses (collections of pus) in the area of the proctodeal glands located around the internal sphincter or a direct infection of one of these anal glands. If there is an inflammation of a proctodeal gland, this causes clogged excretory ducts and finally abscess formation. If these smaller abscesses empty spontaneously or as a result of surgical drainage, the discharged secretion can cause further inflammation. Through tissue remodeling, a stable connective tissue anal fistula subsequently develops as a connecting and transport route for the purulent secretion to the outside. In addition, anal fistulas are associated in rare cases with inflammatory diseases of the intestinal tract such as Crohn’s disease (chronic inflammatory disease of the gastrointestinal tract), diverticulitis (inflammation of the diverticula of the colon), ulcerative colitis (chronic inflammation of the bowel), or cryptitis (inflammatory disease of the rectum).
Symptoms, complaints, and signs
Different symptoms and signs occur in the two stages of anal fistula. In the acute stage, an abscess forms and is usually characterized by pain in the anal area, redness and swelling, and fever. The affected person experiences a general feeling of illness, which increases as the disease progresses. If the abscess opens outward, a fistula develops. At this stage, the original symptoms subside and new symptoms appear. These include oozing, itching and pain, as well as bleeding and pressure points in the affected area. During bowel movements, the fistula may open and bleeding may occur. If pathogens get into the anal fistula, there is a risk of inflammation. Infection is manifested by the fistula increasing in size and causing severe, throbbing pain. Redness also spreads. Externally, an anal fistula can be recognized by its resemblance to a pimple or boil. In addition, fistulas usually persist for a long period of time, often without causing noticeable discomfort. However, a chronic course can lead to skin changes, infections and sensitivity disorders of the skin. Scars may also remain if treatment is lacking or improper.
Diagnosis and course
Anal abscesses and fistulas are classified as belonging to the same clinical picture, with anal fistulas being referred to as a chronic form of the disease and anal abscesses as an acute form of the disease. In contrast to abscesses, which can be very painful, anal fistulas generally cause only minor symptoms and are manifested by chronic weeping, purulent secretions and localized bleeding in the anorectal area, which can cause pustules or pustules in the affected area and contaminated underwear. Occasionally, anal fistulas also manifest themselves on the basis of a temporary stinging sensation. In many cases, the exit of the anal fistula or the external fistula opening is extremely discreet and can only be recognized during a more detailed examination by a depression in the skin level.With complete removal of the anal fistula, the prognosis is very good and about 95 percent heal permanently, whereas with incomplete clefts and chronic inflammatory disease of the gastrointestinal tract, the recurrence rate is higher.
Complications
Anal fistulas can lead to various complications. First, a fistula at the anus worsens control over bowel movements and may cause diarrhea, constipation, and similar digestive problems, for example. Subsequently, it can lead to allergies and hemorrhoids, which are always associated with further discomfort such as itching, infection and inflammation. If the anal fistula is not treated sufficiently or improperly, the fistula ducts continue to enlarge. Often abscesses form, which can lead to blood poisoning if they break open. Due to the constant contact with bacteria, there is an increased risk of the anal fistula becoming inflamed and attacking the sensitive tissue at the anus; this is often accompanied by the development of further anal fistulas and sometimes also by severe pain and itching. During the treatment of anal fistulas, there is often post-operative bleeding, since the open wound is treated. This also poses the risk of infection and the formation of further fistula tracts. As a result, there may be severe scarring, which makes defecation difficult. To avoid this, anal fistulas should be treated immediately after diagnosis.
When should you go to the doctor?
An anal fistula is an inflammation of the anus that should normally disappear completely on its own. However, in some cases, an inflammation can develop from an existing fistula, which absolutely requires medical treatment. Frequently, a strong itching develops in this connection, so that the affected person scratches himself frequently at this place. This can cause the fistula to develop into an open wound, so that in the worst case it can even lead to inflammation. An inflammation of the anus should always be examined by a doctor at an early stage, because otherwise such an inflammation can even develop into an abscess. An abscess is a cavity filled with pus. Under certain circumstances, this fluid can even enter the bloodstream, resulting in life-threatening blood poisoning. If the affected person does not receive appropriate treatment at this point, then of course further complications are to be expected. The bacteria and viruses present can spread throughout the body, resulting in an infection. An increased temperature or even vomiting are the result, so that it is essential to take appropriate medication. Thus, the following applies: an anal fistula can cause a wide variety of complications, which usually require medical treatment.
Treatment and therapy
Since spontaneous remissions are very rarely observed in anal fistulas, they are generally treated by surgical intervention. A frequently used procedure is surgical splitting (fistulotomy) of the fistula canal secured by a button probe under local anesthesia and, if possible, sparing the sphincter apparatus to avoid impairment of fecal continence. In addition, curettage (scraping) of the fistula floor is performed to remove all inflammatory material. The wound trench created by the procedure is kept open until the wound is completely healed, and it should be irrigated regularly and its edges checked. An alternative procedure is the so-called fistulectomy, in which the fistula canal is cut out. However, depending on the course of the anal fistula canal, surgical cutting of muscle areas of the sphincter apparatus may be necessary in some cases, which can lead to fecal incontinence. To avoid impairment of the sphincter apparatus in the case of anal fistulas passing through it, the fistula canal in this area can be closed plastically with fibrin glue or a fistula plug if necessary, although the recurrence rate is somewhat higher in this case. In order to stabilize the local inflammation and minimize the risk of fecal incontinence, in many cases a temporary thread drainage is placed prior to fistula splitting or excision, which can also be used to drain the side ducts of the anal fistula.
Outlook and prognosis
Due to anal fistula, the affected suffer from very unpleasant discomfort and symptoms, so that there is a significant reduction in the quality of life. Most patients suffer from chronic oozing in the process. This not infrequently leads to psychological discomfort or depression, which can significantly limit the old life of the affected person. Furthermore, bloody bowel movements may also occur, which can not infrequently lead to a panic attack. Pus and fistulas can also form as a result of anal fistula, leading to itching or pain. Most patients also suffer from digestive problems due to the complaint and can further die from blood poisoning if the condition is not treated properly. Usually, anal fistula can be removed relatively easily with the help of a surgical procedure. This usually results in the formation of a small scar, which, however, heals. It also completely prevents and limits incontinence. With early treatment, the course of the disease is positive and the patient’s life expectancy is not reduced by the disease. Anal fistula can be prevented by increased hygiene.
Prevention
There are generally no preventive measures against anal fistulas, as they manifest as a result of an abscess or chronic inflammatory bowel disease, against which there is no prophylaxis. Thus, the exact etiology of causative anal abscesses is not fully understood, although frequent constipation, hemorrhoidal symptoms, diarrhea, and certain sexual practices (including anal intercourse) are considered risk factors. However, a change to a high-fiber diet and consistent hygiene of the anal and perianal area is recommended, although anal fistulas can also affect individuals with adequate hygiene. Furthermore, in the presence of a markedly sensitive intestinal and anal mucosa, avoidance of preservatives and fragrances in personal care products is suggested to prevent abscesses and, accordingly, anal fistulas.
Aftercare
Anal fistula is treated surgically in many cases. In this context, aftercare is mainly directed at the wound and its regeneration without complications. Here it is important not to use harsh cleaning agents. Soaps and shower gels are not appropriate here. Showering the wound with lukewarm water is sufficient and is important to prevent coliform bacteria or other pathogens from accumulating in the wound that could cause an infection. Mechanical irritation caused by dry toilet paper as well as wet wipes with chemical additives such as perfumes should also be avoided. Excessive hygiene is not only unnecessary, but can even be harmful in the aftercare. Stool regulation also has a positive effect in connection with aftercare for anal fistula. This should have a soft and voluminous stool as a goal. The patient achieves this by drinking sufficient amounts and eating a diet rich in fiber. Here, the intake of psyllium husks has proven effective. Stool regulation serves to avoid heavy pressing during bowel movements, as this could negatively affect wound healing. Smoking also seems to have an unfavorable effect on anal fistula wound regeneration, so abstaining from nicotine not only benefits general health but also supports anal fistula follow-up care. Contacts for follow-up care of anal fistula are proctologist and family physician.
What you can do yourself
There is no direct prevention against anal fistula. Anal fistulas usually do not heal on their own. Therefore, surgical treatment is often the only effective therapy. The healing process after surgery can take several weeks, or several months in the case of larger fistulas. To support healing, thorough hygiene in the anal area is recommended, which helps to prevent injury and inflammation. It is advisable to clean the wound several times a day during a shower in the period after the operation. Dressing changes and the use of ointments can also help to ensure a high level of hygiene to optimize the wound healing process. Also provide a soft seat cushion so that wound healing is not negatively affected. Bed rest also has a positive effect.In addition, it is advantageous to take certain dietary measures in the period after the operation to prevent constipation or to make bowel movements less unpleasant. A diet as rich in fiber and probiotics as possible, with many whole-grain products and plant-based foods, is recommended for this purpose. In addition, care should be taken to drink sufficient amounts. In addition to water, fruit teas in particular, but also apple, grape and vegetable juices make bowel movements easier.