Anorectal Abscess/Fistula

by: Robert K Cleary MD, John C Eggenberger MD, Amalia J Stefanou, MD

location: Michigan Heart & Vascular Institute, 5325 Elliott Dr, Suite 104
mailing address: PO Box 974, Ann Arbor, MI 48106

Anorectal Abscess and Fistula

WHAT IS AN ANORECTAL ABSCESS/FISTULA ?
An anorectal abscess and fistula are the result of an anal gland infection. Anal glands are
located on the inside where the anus becomes the rectum. When an infection occurs, it
can spread to the buttocks where it presents as a tender, warm, red swelling called an
abscess. If the abscess spontaneously drains, the path between the anal gland infection on
the inside to where the abscess comes to a head on the outside may persist. This may
result in a chronic, intermittent draining opening called a fistula. Symptoms of anorectal
abscesses and fistulas include pain, swelling, drainage, bleeding, constipation, general
feeling of being ill, and rarely urinary difficulties.

An abscess may drain by itself or require drainage by a doctor in the office or emergency
room. After an abscess is drained, it will heal uneventfully about 50% of the time. Or it
may become a chronically draining fistula about 50% of the time.

Abscess and fistulas are classified based on the relationship to the anal sphincter muscles,
those muscle that allow you to control bowel movements.
 ABSCESS FISTULA

Perianal 20% Intersphincteric 70%

Intersphincteric 18% Transsphincteric 23%

Ischiorectal 60% Suprasphincteric 5%

Supralevator 2% Extrasphincteric 2%

AT THE TIME OF YOUR VISIT

When you are seen by the colorectal specialist, you will be asked several questions with
regard to your history. An examination of the anal canal and rectum may be performed.
This may include inspection of the skin around the anus and a digital rectal exam
performed with a well-lubricated gloved finger. This may be followed by the insertion of
a small anoscope which is a small tube placed into the anal canal to better visualize the
anal canal and lower rectum. Rarely, a proctosigmoidoscopy is performed which involves
placing a lighted scope into the rectum and lowermost colon. These examinations usually
cause little or no discomfort. If you present with a tender abscess, inspection of the skin
around the anus may be all that is needed to make the diagnosis.

TREATMENT OPTIONS
Treatment of abscesses and fistulas of the anus and rectum are complex and unique
because of the relationship to the anal sphincter muscles. These muscles control the
passage of gas and stool. The goal of treatment is to eradicate the abscess and fistula and,
at the same time, preserve anal sphincter muscle function. There are many treatment
options. There is a trade-off between success rate and risk. That is, those treatment
options that have the highest chance for success also have the highest risk for fecal
incontinence (leaking gas and stool).

1) EXPECTANT MANAGAMENT

Some patients with fistulas (not abscesses) that cause minimal or no symptoms may elect
not to have surgery and be treated expectantly. There is a small chance that the fistula
tract could become cancer in the future (<1%).

2) SURGICAL OPTIONS

Surgical options are many and depend on the anatomy and complexity of the abscess and
fistula and its relationship to the anal sphincter muscles.

A) Incision and Drainage of Abscess

In the case of an abscess, it may be drained under local anesthetic in the office, or under
general or spinal anesthesia in the operating room, depending on complexity. If the
procedure is performed in the operating room, an attempt may be made to find the
offending anal gland infection. If found, a definitive procedure may be performed to
prevent recurrence. However, this is usually possible only for small abscesses. For most
patients, draining the abscess to address the immediate problem and resolve the infection
is the first priority. After drainage, there is about a 50% chance that the abscess will recur
or persist as a fistula. A more definitive procedure under more elective circumstances
may be required to resolve a fistula.
B) Anal Fistulotomy With or Without Seton
Treatment of an anal fistula (as opposed to some abscesses) is a less urgent problem. The
treatment options are many and varied because fistulas can be simple or complex.
Complex fistulas may have circuitous tracts or involve a significant part of the anal
sphincter muscle. The goal of fistula surgery is to cure the fistula while preserving the
ability to control gas and stool.

At the time of surgery, a probe will be placed in the outside opening near the anus in an
attempt to pass the probe to the inside opening located near the junction between the anus
and rectum where the anal gland infection is located. If the fistula involves only a small
amount of sphincter muscle, then the tract between the inside and outside will be laid
open over the probe, thereby resolving the fistula. This leaves an open wound that
eventually heals in from the inside out over the course of 2-4 weeks. If the fistula
involves a large amount of sphincter muscle, then only part of it will be divided. The
remaining portion of the muscle will be surrounded by a silk thread or rubber band called
a seton. This seton may eventually erode its way through the muscle over the course of
several weeks or months. By eroding through the remaining muscle over time, the seton
thread completes the operation in a fashion that allows the fistula to be ultimately
eradicated with the muscle healing behind it. This potentially preserves the sphincter
muscle function and thereby preserves the ability to control gas and stool. That is, as the
seton makes its way through the remaining muscle, the muscle behind it heals and
remains intact. If the seton does not make its way through the muscle in a defined period
of time (up to 16 weeks or longer) then a second trip to the operating room may be
necessary to divide the remaining fistula tract. This second operation is often less risky
than the first with regard to gas and stool control, because the seton will cause an
inflammatory reaction which allows the muscle to remain in place and not gape when
divided. Rarely, some patients prefer to leave the seton for an indefinite period of time
because for most, it is not an uncomfortable problem to have.
C) ADVANCEMENT FLAP
Another option for the complex anal fistula is the advancement flap. This procedure
involves the development of a flap composed of the inner lining of the rectum. This flap
is drawn over the internal opening where the anal gland infection is located and sutured
beyond it thereby covering the internal opening with the flap. This operation is done
through the anal opening in the operating room under a general or spinal anesthetic. The
advantage of this operation is that little sphincter muscle is divided and the risk for
leaking gas and stool is potentially small. But not every patient’s anatomy is amenable to
this procedure. And while the early results were enthusiastic with success rates close to
80%, more recent literature suggests that this procedure works only about 50% of the
time, and the risk for gas and stool leakage is not 0%. Continence may be affected in up
to 30-50% of patients. In selected patients, it is a viable option.

Instead of developing a flap made of rectal lining, another option is to construct a flap
outside the anus composed of skin and fat that is then moved up into the rectum to cover
the internal opening from the opposite direction. This procedure has success rates similar
to the rectal advancement flap. One would expect more discomfort after surgery with this
skin flap because the flap outside the anus involves cutting and sewing skin (which has
abundant pain fibers) while the cutting and sewing for the rectal flap is all on the inside
where pain fibers are less abundant.

D) FIBRIN SEALANT
This option has been studied at several centers with mixed results. It involves injecting a
substance into the fistula tract that may seal it. It is done under anesthesia in the
outpatient surgery department. The advantage of this procedure is that there is little risk
to the ability to control gas and stool. This must be weighed against the high failure rate.
The failure to resolve the fistula and higher recurrence rates may be disadvantages.
Success rates for simple fistulas have been reported to be 60-70% and for complex
fistulas 14-60%. This option is rarely selected in our practice.

E) ANAL FISTULA PLUG

This is another option studied at several centers with mixed results. A plug of porcine
(pig) collagen is placed into the fistula tract. The edges on both sides are trimmed so that
none of the plug is protruding through the skin. Over time, the collagen plug incorporates
and heals into your own tissues. Like the fibrin sealant, the risk for fecal incontinence is
potentially less than for other procedures because there is less division of sphincter
muscle. Success rates range from 14-84% with more recent literature showing success
rates toward the lower end of the range. We have discovered that some insurance
companies will not cover this procdure.

F) LIGATION INTERSPHINCTERIC FISTULA TRACT (LIFT)

This is another option that has recently gained interest amongst Colon and Rectal
Surgeons because of the potentially decreased risk for leaking gas and stool. A relatively
small incision is made between the internal and external openings in a place called the
intersphincteric groove. The dissection is between the internal and external sphincter
muscle near the anal opening without division of either muscle. When the fistula is
identified between these 2 muscles, it is suture ligated on both sides and divided.

This is an attractive option for selected patients and we are currently offering this
technique to our patients. It is too early to know the long term results but the relative risk
of the procedure should be low compared to procedures that require division of sphincter
muscle.

WHAT TO EXPECT WITH SURGERY

You may be asked to drink a mechanical bowel prep to clean out the colon the day prior
to surgery if a flap procedure is anticipated. Other patients may be asked to take enemas
the day prior to or the morning of surgery. Many patients with abscesses will not need to
prep.

Upon arrival, you will be greeted by the receptionist and other surgery staff, including
nurses and anesthesiologists. The anesthesiologist will discuss anesthetic options that
may include a general or spinal anesthetic. Prior to being taken to the operating suite, you
will be greeted by your colorectal surgeon who will answer any remaining questions. You
will then be taken to the operating suite where an anesthetic will be administered. The
operation will likely last 20-60 minutes. You will then be taken to the recovery room
where you will stay for up to 2 hours. You will then be discharged home with written
instructions. If you do not receive instructions, be sure to ask the recovery room nurse to
ensure that you receive instructions prior to discharge.

RISKS AND COMPLICATIONS OF SURGERY

1) Recurrence
The chance for recurrence is increased if the internal opening associated with the
offending anal gland infection is unable to be found. If the internal opening is able to be
identified and a definitive operation is able to be performed, recurrence rates should be <
10%. In the case of an acute abscess, the goal is to first drain the abscess, often without a
more definitive operation. In these cases, the abscess may recur or become a fistula about
50% of the time. Recurrence after fistula surgery may be related to branch extensions that
are unable to be seen at the original operation. The incidence of recurrence likely
increases with more complex fistulas involving much of the sphincter muscles or with
branch extensions.
2) Incontinence
Studies show that the rates of incontinence vary in the literature from <5% to 50%. The
incidence of loss of fine control of gas and liquid stool is probably higher than the
incidence of leaking solid stool. Complex fistulas that involve greater portions of anal
sphincter muscle are greater risks for this complication. Should this complication occur,
treatment options may include specialized muscle training (biofeedback pelvic floor
retraining) or sphincter muscle repair. In a small percentage of patients, the problem may
be permanent.

3) Bleeding
4) Infection

5) Deep Venous Thrombosis

These are blood clots in the legs that can go to the lungs and can occur after any surgery.
It can cause death and is distinctly rare after this surgery.

6) Heart Attack (rare)

7) Pneumonia (rare)

8) Seton Placement and Staged Procedures

This is not really a complication, but something you should be aware of and is described
in a previous section under the treatment of fistulas. If the fistula involves a large amount
of anal sphincter muscle (complex), it may be necessary to place a silk thread or rubber
band (seton) around the involved muscle. This may require a 2nd operation weeks to
months later to completely resolve the condition. This 2nd operation has attendant risks,
most of which are the same as the original operation.

9) Death (rare)

DISCHARGE INSTRUCTIONS AFTER SURGERY

Diet

Except for those having the fibrin glue or anal fistula plug procedures, there is no special
diet required. You are encouraged to eat a well balanced diet. Since constipation can be a
problem after any operation, your diet should include adequate water intake. Proper diet
combined with moderate activity, such as light walking, should help restore normal
bowel function. Avoid constipation. It is unlikely that the wounds will become infected
or disrupted as a result of having a bowel movement. Though some pain may be
experienced initially after bowel movements, you will be given a prescription for pain
medicine.

NOTE: Those having the fibrin sealant or anal fistula plug procedures should be on
liquids for 72 hours followed by the resumption of a well hydrated regular diet.

Pain Medicine

You will be given a prescription for pain medication to be taken by mouth. One of these
prescriptions may be a narcotic. You should not drive, drink alcohol, perform
strenuous exercises or make important decisions (like sign important papers) while
taking this medication. You should not use a hot stove or equipment that may cause
injury, or be responsible for the care for children. Some of the side effects include:
itching, shortness of breath and constipation. Do not take this medication on an empty
stomach, since it may make you nauseated. Most narcotic pain medications can cause
constipation. You may also be given another pain prescription medication referred to as a
non-steroidal anti-inflammatory drug or NSAID (for example, ibuprofen or Motrin).
This medication is not a narcotic. It may be taken in addition to the prescribed narcotic
medication. However, you should not take more than one NSAID (for example, either
Motrin or aspirin but not both).

Warm Tub or Sitz Baths

(NOTE: Not For Advancement Flaps, Fibrin Sealant, and Anal Fistula Plug)

We will ask you to sit in a warm tub or sitz bath several times a day. Most people prefer
to do this 4 or 5 times a day. The frequency is more important than the duration. For
example, it is better to sit in a warm tub for 15-20 minutes 4 times a day, than to sit for 1
hour twice a day. This will keep your wounds clean and provide you with comfort. The
exception may be patients who have rectal or cutaneous advancement flaps. These
patients may be asked to shower rather than bathe. In addition, those who have fibrin
sealant and fistula plug procedures should not soak in a tub. If you are unsure, call the
office to verify. You may substitute exposing the wounds to shower water instead of tub
baths if you prefer.

Fluids

You should drink plenty of water, up to 6-8 glasses of water per day unless instructed
otherwise by your primary physician because of heart disorders. This is an important step
in preventing constipation, especially for those taking narcotic pain medication.

Constipation

The following are options to avoid constipation. You may try the option that appears
most comfortable for you.
Take a fiber supplement (Metamucil, Citrucel, Fibercon, Benefiber are examples) starting
the evening after surgery. You should take one tablespoon in 8 ounces of water or orange
juice with dinner and with breakfast. In addition, take a stool softener like Colace 100mg
by mouth twice a day. If you do not have a bowel movement within 4-5 days after
surgery, you should call our office. We may recommend another medication to assist you
with this (for example, Milk of Magnesia, Miralax, or an enema). It is very important not
to go four, five or six days after surgery without a bowel movement if this is not your
routine. This can lead to fecal impaction in the rectum that, under the worst of
circumstances, may require a trip to the operating room to remove.

Activity

Have someone stay with you tonight. Restrict your activities and rest for 24 hours.
Resume light to normal activity tomorrow. This would include walking or climbing
stairs. Jogging or running, bicycle riding and other exertional activities should be
avoided until your post-op visit, at which time you will be given further instructions.
You should not drive a car if you are taking narcotic pain medication. Expected time off
from work after this surgery is typically one week.

Other Issues

We should be notified of any problems seemingly related to your operation. Some

specific ones are:

1) A temperature over 100.5 F.

2) Pain not controlled by pain medication.
3) Increased redness, warmth, hardness around operative area.
4) Excessive bleeding. You will have some bleeding. This should not alarm you.
However, if you are soaking pads every few hours, you should call the office.
5) Inability to urinate or the feeling of not being able to empty your bladder
completely.

Questions or Concerns

If any additional problems arise concerning your operation or you need reassurance,
please call our office and ask to speak with one of the office nurses. If you have any
questions, please feel free to contact our office at (734) 712-8150. For more
information, try the American Society of Colon and Rectal Surgeons website at
www.fascrs.org

Other Resources

1) http://www.fascrs.org/physicians/education/core_subjects/2009/anal_fistula_abscess/

2) http://www.nhs.uk/conditions/anal-fistula/Pages/Introduction.aspx
3) http://www.channel4embarrassingillnesses.com/video/in-detail/in-detail-anal-fistula/