Overview
Anal fistulae are chronic abnormal connections between the anal canal and perianal skin or other adjacent structures, often resulting from abscesses and characterized by pain and discharge 1. They predominantly affect young men and can lead to significant morbidity, including fecal incontinence if improperly treated 2.Diagnosis
Clinical History and Examination: Essential for initial assessment 2.
Imaging Techniques:
- Endo-anal Ultrasonography (EAUS): Useful for complex fistulae 2.
- Magnetic Resonance Imaging (MRI): Comparable to EAUS in diagnostic value 2.
- 3D Endoanal Ultrasound (3D-EAUS): Higher accuracy in detecting primary and secondary tracts compared to physical examination; H<sub>2</sub>O<sub>2</sub> enhancement may improve detection of additional fistula components 3.Management
First-Line Treatments:
- Laying Open: Suitable for superficial fistulae; carries risk of incontinence 2.
- Seton Drainage: Alternative to open surgery, reducing risk of incontinence 1.
Adjunctive Treatments:
- Fibrin Glue: Used in certain cases to occlude the fistula 1.
- Collagen Plugs: Another option for occlusion 1.
- Surgical Reconstruction: Involves suturing the sphincter to minimize incontinence risk 2.Special Populations
Pregnancy: Specific management considerations not detailed in provided abstracts 4.
Pediatrics: Not addressed in the abstracts 4.
Elderly: No specific guidelines provided; individualized care recommended based on comorbidities 4.
Comorbidities: Management tailored to minimize impact on existing conditions; sphincter preservation crucial 2.Key Recommendations
Surgical Treatment Based on Fistula Classification: Treat high anal fistulae with sphincter-preserving techniques to reduce risk of fecal incontinence (Evidence: Moderate) 2.
Use of Advanced Imaging Techniques: Employ EAUS or MRI for accurate diagnosis, especially in complex cases (Evidence: Moderate) 23.
Consider Non-Invasive Methods for Superficial Fistulae: Use techniques like fibrin glue or collagen plugs for superficial fistulae to avoid sphincter division (Evidence: Weak) 1.
Probe and Dyes During Surgery: Utilize probing and dyeing techniques during surgery to accurately identify fistula tracts (Evidence: Expert opinion) 2.References
1 Tabry H, Farrands PA. Update on anal fistulae: surgical perspectives for the gastroenterologist. Canadian journal of gastroenterology = Journal canadien de gastroenterologie 2011. link
2 Ommer A, Herold A, Berg E, Fürst A, Sailer M, Schiedeck T. Cryptoglandular anal fistulas. Deutsches Arzteblatt international 2011. link
3 Kim Y, Park YJ. Three-dimensional endoanal ultrasonographic assessment of an anal fistula with and without H(2)O(2) enhancement. World journal of gastroenterology 2009. link
4 Terranova O, Battocchio F, Martella B, Celi D. Anal fistulas with recess above the anal levators. International surgery 1989. link