Two rings of muscle above your anus control your continence. Together these are the anal sphincter muscles. An anal fistula is an abnormal connection between the inside and outside of the anus/rectum, often passing through one or both anal sphincter muscles. It provides a passage for pus and/or poo to pass to the outside, bypassing the anus. Blockage of this passage can cause an abscess (pain, swelling, feeling unwell).
They are most commonly caused by infection of the lubricating anal glands. Those that fail to heal, can form a fistula. People with Crohn’s proctitis are especially prone to these problems.
Yes, though this can sometimes take time and patience.
Treatment aims are two-fold:
- to treat the symptoms of your fistula
- to maintain your continence.
The first step is to make sure that the fistula can drain. This may need an emergency operation if you are unwell.
Widening of the external opening, cleaning out the tract, and placing a seton can all help this
A seton is a loose piece of surgical thread that sits in the fistula tract, and helps it to drain. It should be comfortable.
The mainstay of curative treatment for fistula is a fistulotomy, also known as a "lay open". A probe is passed down the tract, and a surgical cut is made to divide skin and muscle down to the tract. The tract is cleaned and then allowed to heal. This represents cure in 95% of cases.
Surgeons are careful not to perform fistulotomy if they think there is a chance of impairing your continence. This wil depend on the amount and quality of muscle that would be left behind to control your bowel habit.
Where the fistula tract incorporates a lot of muscle, it is termed a “high fistula”. These are not suitable for fistulotomy, as there is a good chance it would impair your long term bowel continence.
There are two safer management options:
- long term seton
Long term setons are safe, and often do not interfere with day-to-day activities. They help to prevent episodes of abscess. They can be turned through 360 degrees to help clear any debris that gets stuck in the tract.
- sphincter preserving procedure
This involves cleaning of the tract, and attempting to close it using heat and sutures. It usually requires a period of time with a seton to prepare the tract. The success rates are usually around 50% each time.
You will usually be sent home on the same day, with instructions.
- It is likely that you will have local anaesthetic around the wound, so some areas may be numb. This will wear off, and it is important to take regular paracetamol and/or ibuprofen for the first 5 days.
- It is important that you take baths/showers daily. Avoid perfumed soaps or gels, as these can sting. Gently dry the area with paper or a clean towel.
- If your doctor has asked you to “digitate the wound”, when washing, run your finger gently around and in the wound, so that healing occurs from the floor of the cavity up. This avoids formation of a cavity that heals over.
- Wear an absorbant pad in your pants, as the fistula may dribble.
- Avoid adhesive dressings on the skin that block the drainage.
- It is not unusual to get a small amount of fresh bleeding in the days after the operation
- Sometimes the edge of the wound will have tiny stitches. These are keeping the wound open during the days after the surgery, and will fall out or be broken down by the body over time.
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