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Anal abscess and fistula

Mappes HJ, Farthmann EH.

Publication Details

Anal fistulae and abscesses of the perianal region

are different manifestations of the same clinical
disease. Although spontaneous recovery occurs
recurrence is most common without adequate
surgical therapy (grade C).

Perianal abscesses usually develop from the

proctodeal glands which originate from the
intersphincteric plane and perforate the internal
sphincter with their duct. The abscesses may
break through into the anal canal and resolve
completely (4), but they can also spread by a
submucosal, intersphincteric or transsphincteric
route and develop into fistulae.

Classification and pathological

anatomy
A review of the literature shows a wide variation
in classification and nomenclature of perianal
fistulae and abscesses. Therefore, in this paper the
classification based on A. Parks is used.
According to this, the classification of anorectal
abscesses and fistulae is given by their location
(figure 1).

Figure 1
a. Typical location and extent of
anorectal abscess and fistula: 1
intersphincteric, 2 transsphincteric
(ischiorectal), 3 extrasphincteric, 4
submucosal. b. Therapy: abscess
incision and incision/excision of fistula.

Superficial infections may lead to submucosal or

subcutaneous abscesses. If the abscess perforates
the external sphincter, an ischiorectal abscess
develops. If the intersphincteric abscess spreads
cranially beyond the levator muscles, a pelvirectal
abscess results. Semicircular and, mostly,
posterior progression of the infection leads to a
horseshoe abscess or fistula formation.

A fistula develops as the result of spontaneous

perforation of the abscess, or of surgical incision.
If the external and internal (anal) ostium can be
verified by examination, the so called complete
fistula will be treated as later shown. An
incomplete fistula has only one orifice.

Symptoms

Abscess
Superficial abscesses (subcutaneous, submucosal,
ischiorectal abscesses) show typical symptoms
such as pain, swelling, tenderness, fever. Due to
their anatomic location, they often cause
discomfort on walking and sitting. Usually the
vicinity to the anal canal causes painful
defecation.

Deep abscesses (intermuscular, pelvirectal) often

lack typical symptoms. Diffuse pelvic pain and
raised body temperature are found occasionally.

Besides physical examination, including rectal-

digital examination, CT, MRI or endosonography
have proven to give information about deeper
abscesses (grade B and C).

Fistulae
The symptoms of perianal fistulae depend on the
severity of inflammation. Bland fistulae may
excrete pus, sometimes serous fluid and rarely
feces, leading to pruritus ani, itching and skin
maceration. Severe symptoms occur only
occasionally, when spontaneous closure of the
fistula leads to recurrent abscess formation.

Diagnosis
Diagnostic procedures are aimed at the exact
localization of the abscess or fistula in order to
perform adequate surgical therapy leading to full
functional recovery of the patient.

Abscess
The clinical diagnosis is made by inspection and
palpation. If possible, rectoscopy/proctoscopy
should be performed, although in the case of an
acute abscess this may be too painful. For deeper
abscesses imaging procedures may be employed.
Transanal endosonography and MIR have shown
good results (5, 8) (grade B and C).

Fistulae
Besides obligatory recto- and proctoscopy the
diagnosis of fistulae may include the instillation
of methylene blue solution. The course of the
fistulae can be identified with various probes.

Occasionally, endosonography, if necessary with

contrast medium, and lately MRI have been
helpful to establish the appropriate therapeutic
strategy (5, 6, 8).

Some authors advocate preoperative manometry

in order to choose the therapeutic management
according to the risk of incontinence (grade B).

Therapy

Abscesses
Anorectal abscesses are incised and laid open on
the shortest route. The location of the abscess
determines the surgical approach. The operation
should be performed under regional or general
anesthesia.

In subcutaneous or submucosal abscesses located

within the outer anal canal, a skin excision should
be performed to create free drainage and to
prevent early closure of the skin. In perianal
abscesses synchronous fistulotomy seems not to
impair functional outcome (grade C).

Intermuscular abscesses can be drained

transanally to the inside of the anal canal. The
abscess cavity is opened by incision of the
anoderm and the internal sphincter overlying the
abscess. Ischiorectal abscesses are opened by a
sufficiently large skin incision into the
ischiorectal fossa (6), a synchronous fistulotomy
does not seem to be necessary (grade B and C).

Drainage of pelvirectal abscesses can also be

performed perineally, provided the levators are
opened wide enough to assure adequate drainage.

In a pelvirectal abscess with a fistula towards the

rectum, the drainage may also be performed
transanally.

Anal fistula
Fistulae should be classified prior to surgery,
since the crucial point for the right surgical
approach and functional results is the exact
preoperative localization of the tract of the fistula
(grade B and C). Fistulotomy of subcutaneous or
submucosal fistulae can be performed with a
probe. No extra excision of the fistulous tract is
necessary, the wound can remain open for
secondary healing. Exact localization of the inner
opening of the fistula can be attained by
endosonography or by probes. Alternatively,
some authors describe techniques using primary
closure or marsupialization of the wound edges to
the fistula ground to obtain better functional
results and/or earlier healing (grade B).

If less than the distal two thirds of the internal

sphincter muscle are involved the respective
distal sphincter parts and the anoderm can be cut
as previously described for subcutaneous fistulae.
Impaired continence is unlikely to develop. The
wound should also remain open for secondary
healing. Recent literature suggests an approach
which preserves the sphincter better, because
follow-up studies after surgery for fistula-in-ano
often show a decreased sphincter tonus and
impaired continence. This observations,
combined with EUS findings of occult sphincter
damage after fistulotomy with division of the
internal sphincter is used as argument for
sphincter-preserving procedures (as described for
transsphincteric fistulae (grade B and C)).

Transsphincteric fistulae
If more than two thirds of the sphincter muscle
are affected, division of the sphincter muscle
without loss of continence is unlikely. Therefore,
it is recommended not to severe the sphincter
muscle. Even if there will be no incontinence at
first, physiological aging may cause muscular
weakening in the long-term (grade C).

Staged procedures are sometimes necessary. In a

first step the fistula is identified and marked with
a seton. This may require anesthesia (1, 7, 9). At
the same time, external tracts of the fistula are
laid open. If there are no inflammatory changes or
if inflamed tissue can be resected, closure of the
internal ostium may be achieved by single stitch
sutures. More often a second intervention is
necessary to excochleate the remaining outer part
of the fistula, if excision is not possible. The inner
ostium is excised out of the sphincter muscle, the
muscle is sutured and the row of sutures is
covered by a mucosal advancement flap (2, 3),
which is dissected from the mucosa cephalad to
the internal aperture and sutured to the lower
margin of the mucosa (figure 2). Alternatively a
full-thickness rectal (wall) advancement flap may
be used, showing better results in certain
indications (grade B and C).

Figure 2
Sliding flap. a, b. Coring out of all the
fistulous tract and anal gland. c.
Mobilization of a mucosal flap. d.
Closure of muscular gap. e. of the
mucosa.

Extrasphincteric fistulae
The cure of extrasphincteric fistulae may also
include several surgical procedures. In a first step
the outer part of the fistula should be excised. If
the internal orifice can be securely identified, the
fistula can be closed either using a mucosal or
rectal advancement flap or with direct suture
protected by a diverting colostomy (2, 3).

Some authors recommend the use of a cutting

seton to avoid surgical division of the sphincter
apparatus. The published data show good
functional and satisfying results, although the
therapy needs a long time (grade C).

Recto-vaginal fistulae
A particular form of fistula is the recto-vaginal
fistula. Exact preoperative diagnosis is essential
to determine exactly size and localization, to
assess the stage of the anal sphincter, and to
reveal the cause of the fistula such as Crohnís
disease, radiation, obstetric injury, neoplasia,
operative trauma. The surgical approach depends
on the level of the opening of the fistula into the
rectum and into the posterior wall of the vagina
[2].

Recto-vaginal fistulae have to be differentiated

from ano-vaginal fistulae which originate from
the anal canal distal to the dentate line. Recto-
vaginal fistulae are classified according to their
location, size, and etiology. Most surgeons
arbitrarily classify a fistula as low when it can be
repaired from a perineal approach and as high if it
can be approached only transabdominally. The
size of recto-vaginal fistulae ranges from less
than 0.5 cm (small) to more than 2.5 cm (large).

The timing of the operation is determined by the

likelihood of spontaneous or non-operative
healing of the fistula. About one half of small
recto-vaginal fistulae secondary to obstetric
trauma may heal spontaneously, whereas recto-
vaginal fistulae due to inflammatory bowel
disease and radiation therapy of neoplasia rarely
will. For this reason in certain cases a
conservative approach for up to six months is
recommended, which should be used to improve
the patientís general condition.

For high fistulae closing should be performed

from an abdominal approach. After mobilizing
the rectum the fistula is transsected. Alternatively
a low anterior resection of the rectum may
become necessary.

Recto-vaginal fistulae opening into the distal

suprasphincteric part of the rectum can be treated
by a mucosal or rectal advancement flap [2]. This
requires a deviation enterostomy or adequate
bowel preparation followed by parenteral
nutrition.

After dissection of the mucosal flap the fistulous

tract is carefully excised from the muscle and the
posterior wall of the vagina, followed by suture
closure of the muscle. These sutures will be
covered by the mucosal flap. The vaginal side of
the fistula remains open.

Prior to operation exact evaluation of the

sphincter muscle is mandatory. To avoid bad
functional outcome additional sphincteroplasty
may be required [grade C].

In conclusion, surgery of perianal abscesses and

fistulae show many possible variations. As shown
in the literature the surgeonís knowledge about
anatomy and function, experience, technical skills
and patience of both patient and surgeon is
needed to achieve satisfying results [grade B and
C].

References
1. Ackermann C, Tondelli P, Herzog U.
Sphinkterschonende Operation der
transsphinkteren Analfistel. Schweiz Med
Wschr/J Suisse Med. (1994);124:1253–1256.
[PubMed]
2. Athanasiadis S, Oladeinde I, Kuprian A,
Keller B. Endorektale
Verschiebelappenplastik vs. Transperinealer
Verschluss bei der chirurgischen Behandlung
der rektovaginalen Fisteln. Eine prospektive
Langzeitstudie bei 88 Patientinnen. Chirurg.
(1995);66:493–502. [PubMed]
3. Farthmann E H, Ruf G. Zur Problematik der
Kontinenzerhaltung bei der Behandlung von
IBD-assoziierten Analfisteln. Schweiz
Rundsch Med Prax. (1997);86:1968–1070.
[PubMed]
4. Hamalainen K P, Sainio A P. Incidence of
fistulas after drainage of acute anorectal
abscesses. Dis Colon Rectum.
(1998);41:1357–1361. [PubMed]
5. Poen A C, Felt-Bersma R J, Eijsbouts Q A,
Cuesta M A, Meuwissen S G. Hydrogen
peroxide-enhanced transanal ultrasound in the
assessment of fistula-in-ano. Dis Colon
Rectum. (1998);41:1147–1152. [PubMed]
6. Sailer M, Fuchs KH, Kraemer M, Thiede A
(1998) Stufenkonzept zur Sanierung
komplexer Analfisteln. Zbl Chir 123: 840–
805; discussion 846 . [PubMed]
7. Spencer J A, Chapple K, Wilson D, Ward J,
Windsor A C, Ambrose N S. Outcome after
surgery for perianal fistula. Am J Roentgenol.
(1998);171:403–406. [PubMed]
8. Stoker J, Fa V E, Eijkemans M J, Schouten W
R, Lameris J S. Endoanal MIR of perianal
fistulas: the optimal imaging planes. Eur
Radiol. (1998);8:1212–1216. [PubMed]
9. Van Tets W F, Kuijpers J H. Seton treatment
of perianal fistula with high anal or rectal
opening. Br J Surg. (1995);82:895–897.
[PubMed]

Publication Details

Author Information

Authors

H.J. Mappes and E.H. Farthmann.

Affiliations

Department of Surgery, University od Freiburg, Freiburg,

Germany

Copyright
Copyright © 2001, W. Zuckschwerdt Verlag GmbH.

Publisher

Zuckschwerdt, Munich

NLM Citation

Mappes HJ, Farthmann EH. Anal abscess and fistula. In:

Holzheimer RG, Mannick JA, editors. Surgical Treatment:
Evidence-Based and Problem-Oriented. Munich:
Zuckschwerdt; 2001.

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