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Benign Anorectal: Abscess and Fistula. Seema Izfar, MD. 12/21/11. Benign Anorectal: Abscess and Fistula. anorectal abscess and fistula-in-ano represent different stages of the same disease the abscess represents the acute inflammatory event the fistula represents the chronic process.

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Benign anorectal abscess and fistula
Benign Anorectal: Abscess and Fistula

  • Seema Izfar, MD


Benign anorectal abscess and fistula1
Benign Anorectal: Abscess and Fistula

  • anorectal abscess and fistula-in-ano represent different stages of the same disease

    • the abscess represents the acute inflammatory event

    • the fistula represents the chronic process

Benign anorectal abscess and fistula2
Benign Anorectal: Abscess and Fistula

  • diagnosis and treatment requires in-depth understanding of anorectal anatomy and spaces

Benign anorectal abscess and fistula3
Benign Anorectal: Abscess and Fistula

  • at the dentate line, the ducts of the anal glands empty into anal crypts

  • 80% are submucosal, 8% extend to internal sphincter, 8% to the conjoined longitudinal muscle, 2% intersphincteric, 1% penetrate internal sphincter

  • 90% of anorectal abscess result from crytogladular infection

  • Parks cryptoglandular theory - obstruction of anal glands leads to stasis and infection


  • classified by location: perianal, ischioanal, intersphincteric, supralevator

  • perianal abscess most common, supralevator most rare

  • pain, swelling, fever hallmark symptoms

    • supralevator abscess may have gluteal pain

    • rectal pain with urinary symptoms - possibly indicate intersphincteric or supralevator abscess

Abscess etiology
Abscess - Etiology

  • nonspecific cryptoglandular (90%)

  • specific causes:

    • inflammatory bowel disease,

    • specific infection, ie TB, actinomycosis, lymphogranuloma venereum,

    • trauma or foreign body

    • surgery (episiotomy, hemorrhoidectomy, prostatectomy),

    • malignancy - carcinoma, lymphoma, radiation-related

Abscess treatment
Abscess - Treatment

  • exam under anesthesia for pain out of proportion to exam

  • incision and drainage - trim edges to prevent coaptation

  • I&D of supralevator abscess:

    • depends on location - intersphincteric origin then divide internal sphincter and drain into rectum; if arises from ischianal abscess can be drained through perineal skin

Abscess treatment1
Abscess - Treatment

  • catheter drainage: stab incision to drain pus, mushroom catheter in cavity to drain pus

    • make stab incision as close as possible to anus

    • size and length of catheter should correspond to abscess cavity

Abscess treatment2
Abscess - Treatment

  • primary fistulotomy

    • may be easier to identify tract

    • eliminates source of infection

    • decreases recurrence/need for reoperation

  • downsides: false passage formation with acute inflammation, 30-50% of those with abscess likely won’t develop a fistula, need for anesthesia vs. local for I & D

  • Abscess antibiotics
    Abscess - Antibiotics

    • little or no role except in case of valvular heart disease, prosthetic devices, severe cellulitis, diabetes, immunosuppression

    Abscess complications
    Abscess - Complications

    • Recurrence

      • recurrence in as many as 89% of pts

    • Extra-anal causes

      • should be evaluated for recurrent disease (hidradenitis suppurativa, Crohn’s)

    • Incontinence

      • iatrogenic (superficial external sphincter), inappropriate wound care (excessive scarring from prolonged packing)

    Abscess complications1
    Abscess - Complications

    • can result in necrotizing anorectal infection (rare)

    • resuscitation, IV abx, wide debridement to healthy tissue

    • need for colostomy debatable - recommended if sphincter muscle is grossly infected, immunocompromised, rectal or colonic involvement/perforation

    • reexamination under anesthesia

    • HBO - 100% O2 at 3atm over 2 hrs - promote leukocyte phagocytic function and fibroblast proliferation

    Anal infection and hematologic diseases
    Anal Infection and Hematologic Diseases

    • anorectal suppuration with acute leukemia with mortality 45-78%

    • neutrophil count <500 with 11% incidence of anorectal abscess

    • most important prognostic factor - # days of neutropenia

    • presenting symptoms: fever, pain, urinary retention

    • antibiotics vs I & D if fluctuance, sepsis, or progression of soft tissue infection after antibiotics trial

    Anal infection hiv
    Anal Infection & HIV

    • HIV+ pts have increased risk of perianal sepsis

    • can be associated with in situ neoplasia

    • surgery + antibiotics 2/2 immunosuppression

      • make incison site small bc pts at risk for poor wound healing

    Fistula in ano

    • abnormal communication between any two epithelium-lined surfaces

    • Parks classification:

    Intersphincteric fistula in ano
    Intersphincteric Fistula-in-ano

    • most common type of fistula - 70%

    • results from perianal abscess

    • variations:

      • simple low tract

      • high tract with rectal opening or blind tract

      • extrarectal extension

      • pelvic disease tracking

    Transsphincteric fistula
    Transsphincteric Fistula

    • approx 23% fistulas

    • results from ischioanal absecesses

    • rectovaginal fistula is a form of transsphincteric fistula

    • operative mgt with setons if sphincter preservation in question

    Suprasphincteric fistula
    Suprasphincteric Fistula

    • 5% of fistulas

    • result from supralevator abscesses

    • tract arises from intersphincteric abscess, travels above puborectalis, then downward lateral to external sphincters in ischioanal space

    Extrasphincteric fistula
    Extrasphincteric Fistula

    • 2% of fistulas - rarest form

    • from rectum above the levators, through them, to the perianal skin

    • trauma, foreign body, Crohn’s carcinoma

    • most common cause is iatrogenic from probing during fistulotomy surgery

    Fistula in ano physical examination
    Fistula-in-ano: Physical Examination

    • Goodsall’s rule:

      • transverse line across the perineum -

      • posterior external openings have internal openings in the posterior midline

      • anterior external openings have tract radially toward the nearest crypt

      • greater distance from anal margin with more variability

      • more accurate rule for posterior fistulas

    Fistula in ano treatment
    Fistula-in-ano: Treatment

    • eliminate fistula,

    • prevent recurrence,

    • preserve sphincter function

    Fistula in ano treatment1
    Fistula-in-ano: Treatment

    • identification of internal opening

      • passage of probe

      • injection of dye, milk, or hydrogen peroxide

      • following granulation in fistula tract

      • noting puckering of crypt with traction on fistula tract

    Fistula in ano operative management
    Fistula-in-ano: Operative Management

    • Lay-open technique: identification of tract with unroofing tract +/- marsupialization

    • appropriate for simple interspincteric and low transsphincteric

    Fistula in ano operative management1
    Fistula-in-ano: Operative Management

    • Seton - placement of non-absorbable suture material in fistula tract

    • indications for setons:

      • promote fibrosis around fistula tract that encircles entire sphincter mechanism

      • mark the site of fistula in massive anorectal sepsis

      • anterior high transsphincteric fistulas in women

      • HIV pts with poor wound healing and high transsphincteric fistulas

      • Crohn’s

      • any time continence is questioned

    Fistula in ano operative management2
    Fistula-in-ano: Operative Management

    • high-transphincteric fistulas can be treated with combination lay-open technique and seton placement - division of internal sphincter to level of external opening and then seton placement

    • cutting setons can convert high fistulas to low fistulas

    • second-stage fistulotomy ~ 8 wks later

    Fistula in ano operative management3
    Fistula-in-ano: Operative Management

    • suprasphincteric fistula - tract involves external sphincter and puborectalis -

      • can manage with division of internal sphincter and superficial external sphincter with seton around remaining ES

      • or internal sphincterotomy, seton, opening of fistula tracts without division of external sphincter

    Fistula in ano operative management4
    Fistula-in-ano: Operative Management

    • Anorectal Advancement Flap

      • internal opening closed with absorbable suture, full-thickness flap of rectal mucosa/submucosa/IAS raised - adv 1 cm beyond internal opening

      • base of the flap should be twice the width of the apex

      • pros: reduction in healing time, reduced pain, little potential damage to sphincters, lack of deformity to anal canal

      • poor outcomes in Crohn’s, pts on steroids, smokers, o/w success reported in up to 90% of pts

    Fistula in ano operative management5
    Fistula-in-ano: Operative Management

    • Fibrin Glue - used in conjuntion with AAF or alone

    • technique: internal and external openings identified, tract curetted, fistula tract injected through connector from external opening until glue visible in internal opening, slowly withdrawn

    • can be repeated several times without compromising continence

    Fistula in ano operative management6
    Fistula-in-ano: Operative Management

    • Fibrin Glue - Followup:

    • short-term follow-up with good success 70-80%

    • longer follow-up with success falling to 60% and even 14% in pts with complex anal fistulas

    Fistula in ano operative management7
    Fistula-in-ano: Operative Management

    • bioprosthetic fistula plug made from surgisis

    • technique - identification of internal and external opening with placement of plug over probe using suture similar to seton placement

    • plug secured at primary opening using absorbable suture

    Fistula in ano operative management8
    Fistula-in-ano: Operative Management

    • technique works best with long tracts without active inflammation or sepsis

    • short-term follow up (3months) with higher success rate for Crohn’s fistulas when compared to fibrin glue

    • long-term follow up - high failure rate

    Crohn s and anal fistulas
    Crohn’s and Anal Fistulas

    • the most common perianal manifestation and occur in 6-34% Crohn’s pts - pts with colonic Crohn’s with higher incidence, rectal Crohn’s with 100% fistula formation

    • conservative approach to treatment as 38% heal without surgery

    Crohn s and anal fistulas1
    Crohn’s and Anal Fistulas

    • medications for treatment: cipro/flagyl, immunomodulators (steroids, 6MP, azathioprine, infliximab)

    • 6-MP and azathioprine only effective in 1/3 pts with fistulizing Crohn’s

    • Infliximab associated with 62% reduction

    • combination 6MP and infliximab may prolong effect of treatment

    • selective seton placement with infliximab + maintenance med with healing in 67%

    Crohn s and anal fistulas2
    Crohn’s and Anal Fistulas

    • operative intervention: seton placement, rectal advancement flap if rectal-sparing, poss fibrin glue/plug

    • avoid cutting sphincter - incontinence reported in pts with Crohn’s proctitis even without anal surgery