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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.
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.
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
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
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.
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)
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