Fistula-in-Ano

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A fistula-in-ano is an abnormal hollow tract or cavity that is lined with granulation tissue and that connects a primary opening inside the anal canal to a secondary opening in the perianal skin; secondary tracts may be multiple and can extend from the same primary opening. It should be differentiated from the following processes, which do not communicate with the anal canal:

Most fistulas are thought to arise as a result of cryptoglandular infection with resultant perirectal abscess. The abscess represents the acute inflammatory event, whereas the fistula is representative of the chronic process. Symptoms generally affect quality of life significantly, and they range from minor discomfort and drainage with resultant hygienic problems to sepsis.

References to fistula-in-ano date to antiquity. The fascination fistula-in-ano has exerted for more than 2000 years is manifested by the numerous papers and books on the subject. Hippocrates, in about 430 BCE, made reference to surgical therapy for fistulous disease, and he was the first person to advocate the use of a seton (from Latin seta “bristle”).

In 1376, the English surgeon John Arderne (1307-1390) wrote Treatises of Fistula in Ano; Haemmorhoids, and Clysters, which described fistulotomy and seton use. Historical references indicate that Louis XIV was treated for an anal fistula in the 18th century. Salmon established a hospital in London (St. Mark’s) devoted to the treatment of fistula-in-ano and other rectal conditions. ^[1]

In the late 19th and early 20th centuries, prominent physician/surgeons, such as Goodsall and Miles, Milligan and Morgan, Thompson, and Lockhart-Mummery, made substantial contributions to the treatment of anal fistula. These physicians offered theories on pathogenesis and classification systems for fistula-in-ano. ^{[2, 3]}

Since this early progress, little has changed in the understanding of the disease process. In 1976, Parks refined the classification system that is still in widespread use. Over the past few decades, many authors have presented new techniques and case series in an effort to minimize recurrence rates and incontinence complications, but despite more than two millennia of experience, fistula-in-ano remains a perplexing surgical disease.

Treatment of fistula-in-ano remains challenging. ^[4]  No definitive medical therapy is available for this condition, though long-term antibiotic prophylaxis and infliximab may have a role in recurrent fistulas in patients with Crohn disease. Surgery is the treatment of choice, with the goals of draining infection, eradicating the fistulous tract, and avoiding persistent or recurrent disease while preserving anal sphincter function. ^{[5, 6]}

For patient education information, see the Digestive Disorders Center, as well as Anal Abscess, Rectal Pain, and Rectal Bleeding.

A thorough understanding of the pelvic floor and sphincter anatomy is a prerequisite for clearly understanding the classification system for fistulous disease. (See the image below.)

The external sphincter muscle is a striated muscle under voluntary control by three components: submucosal, superficial, and deep muscle. Its deep segment is continuous with the puborectalis and forms the anorectal ring, which is palpable upon digital examination.

The internal sphincter muscle is a smooth muscle under autonomic control and is an extension of the circular muscle of the rectum.

In simple cases, the Goodsall rule can help anticipate the anatomy of a fistula-in-ano. This rule states that fistulas with an external opening anterior to a plane passing transversely through the center of the anus will follow a straight radial course to the dentate line. Fistulas with their openings posterior to this line will follow a curved course to the posterior midline (see the image below). Exceptions to this rule are external openings lying more than 3 cm from the anal verge. These almost always originate as a primary or secondary tract from the posterior midline, consistent with a previous horseshoe abscess. ^{[7, 8]}

The classification system developed by Parks, Gordon, and Hardcastle (generally known as the Parks classification) is the one most commonly used for fistula-in-ano. This system (see the image below) defines four types of fistula-in-ano that result from cryptoglandular infections, as follows ^[9] :

An intersphincteric fistula-in-ano is characterized as follows:

A transsphincteric fistula-in-ano is characterized as follows:

A suprasphincteric fistula-in-ano is characterized as follows:

An extrasphincteric fistula-in-ano is characterized as follows:

Current procedural terminology codes classification

Current procedural terminology coding includes the following:

Unlike the current procedural terminology coding, the Parks and colleagues classification system developed by Parks et al does not include the subcutaneous fistula. These fistulas are not of cryptoglandular origin but are usually caused by unhealed anal fissures or anorectal procedures (eg, hemorrhoidectomy or sphincterotomy).

In the vast majority of cases, fistula-in-ano is caused by a previous anorectal abscess. Typically, there are eight to 10 anal crypt glands at the level of the dentate line in the anal canal, arranged circumferentially. These glands penetrate the internal sphincter and end in the intersphincteric plane. They provide a path by which infecting organisms can reach the intramuscular spaces. The cryptoglandular hypothesis states that an infection begins in the anal canal glands and progresses into the muscular wall of the anal sphincters to cause an anorectal abscess.

After surgical or spontaneous drainage in the perianal skin, a granulation tissue–lined tract is occasionally left behind, causing recurrent symptoms. Multiple series have shown that formation of a fistula tract after anorectal abscess occurs in 7-40% of cases. ^{[10, 11]}

Other fistulas develop secondary to trauma (eg, rectal foreign bodies), Crohn disease, anal fissures, carcinoma, radiation therapy, actinomycoses, tuberculosis, and lymphogranuloma venereum secondary to chlamydial infection.

The true prevalence of fistula-in-ano is unknown. The incidence of a fistula-in-ano developing from an anal abscess ranges from 26% to 38%. ^{[5, 12]} One study showed that the prevalence of fistula-in-ano is 8.6 cases per 100,000 population. In men, the prevalence is 12.3 cases per 100,000 population, and in women, it is 5.6 cases per 100,000 population. The male-to-female ratio is 1.8:1. The mean patient age is 38.3 years. ^[13]

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Juan L Poggio, MD, MS, FACS, FASCRS Associate Professor of Surgery, Chief, Division of Colorectal Surgery, Department of Surgery, Drexel University College of Medicine

Juan L Poggio, MD, MS, FACS, FASCRS is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.

John Geibel, MD, DSc, MSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Oscar Joe Hines, MD Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine

Oscar Joe Hines, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Endocrine Surgeons, American College of Surgeons, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: RFA Medical None Director; MRC Biotec None Director

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Dennis F Zagrodnik II, MD, FACS Consulting Staff, Premier Surgical of Wisconsin, SC

Dennis F Zagrodnik II, MD, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Phi Beta Kappa, Society of American Gastrointestinal and Endoscopic Surgeons, Southeastern Surgical Congress, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

Fistula-in-Ano

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