Fistula In Ano

Kishore SR
Oman Medical College
Contents

• Anatomy

• Etiology

• Clinical features

• Assessment and Investigations

• Management
Anatomy of the Anal Canal
Etiology

• Obstruction of the Anal Gland

▫  In the vast majority of cases, fistula-in-ano is caused by a previous
anorectal abscess. (cryptoglandular infection)
• Iatrogenic
• Crohn’s disease
• Anorectal trauma
• Anorectal Carcinoma
• Others (radiation therapy, actinomycoses, tuberculosis, and
lymphogranuloma venereum secondary to chlamydial infection)
Clinical Features

• Patients often provide a reliable history of previous pain, swelling,

and spontaneous or planned surgical drainage of an anorectal
abscess. Signs and symptoms of fistula-in-ano, in order of
prevalence, include:
• Perianal discharge
• Pain
• Swelling
• Bleeding
• Diarrhea
• Skin excoriation
• External opening
Assessment and Investigations
• Physical examination under Anesthesia
is the mainstay of diagnosis.
• Digital rectal examination (DRE) may
reveal a fibrous tract or cord beneath
the skin
• Anoscopy is usually required to identify
the internal opening.
• Proctoscopy is also indicated in the
presence of rectal disease (e.g., Crohn
disease or other associated
conditions).
• MRI for high complex fistulas
• Goodsall’s Rule
Management

• Low lying fistulas can be simply laid

open and allowed to heal.
• In complex ones involving the
sphincter, it can be probed using a
lacrimal probe and seton is passed
and allowed to drain.
• A tighter seton will gradually cut
through the sphincters and allow to
heal behind the seton.
• High fistulas can be treated with an anorectal
advancement flap.
Thank you