Anal Fistula

Dr. Sulaiman Bin Yusof

MbChB (Sheffield) M.Med (Surg) FRCSEd (Gen Surg)
蘇萊曼·尤索夫博士

What is an Anal Fistula?

An anal fistula is a small tunnel that develops between the end of the bowel (the rectum) and the skin near the anus.

The anus contains small glands that produce fluid to aid bowel movements. If one of these glands becomes blocked or infected, an abscess forms, which is a pus-filled pocket. If the abscess does not heal properly, it can form a fistula, which is an abnormal connection between the gland and the skin.

Symptoms of an Anal Fistula

An anal fistula can cause several symptoms, each related to how the fistula affects the body.

Pain: Discomfort occurs when a fistula forms a pathway from an infected area inside the anus to the skin outside, causing inflammation and irritation.

Swelling: The presence of a fistula results in ongoing infection or inflammation in the tissues around the anus, leading to swelling that can be felt as a tender lump near the anus.

Discharge: A fistula often allows pus, blood, or other fluid to drain through the opening in the skin. The presence of a constant or intermittent discharge is a significant symptom indicating an ongoing infection.

Irritation: Continuous leakage of pus or other fluids from the fistula can irritate the surrounding skin, causing itching, redness, and discomfort in the anal area.

Recurrent Abscesses: If an initial abscess does not heal properly, it may lead to the formation of a fistula, which can cause recurrent infections and abscesses. These abscesses can cause significant pain and swelling each time they occur.

Foul Odour: Drainage from a fistula can produce an unpleasant odour, mainly due to the infected pus or fluid.

Causes & Risk Factors

Several factors can lead to the formation of an anal fistula, often starting with an infection.

Anal Gland Infection

If an anal gland becomes blocked and infected, it can lead to the formation of an abscess. If the abscess does not heal properly or is not fully drained, it may create a fistula. This is the most common cause of anal fistulas.

Crohn’s Disease

This is a chronic inflammatory bowel condition that weakens the tissue and can cause sores that may eventually develop into fistulas.

Ulcerative Colitis

Another type of inflammatory bowel disease that affects the lining of the colon and rectum. Chronic inflammation in these areas can lead to ulcers that may develop into fistulas if infected.

Cancer

Tumours in the rectum or anus can cause blockages or pressure on surrounding tissues, resulting in infection and the formation of abscesses that can develop into fistulas.

Diagnosis of Anal Fistula

Diagnosing an anal fistula involves several steps to ensure accurate assessment and appropriate treatment:

Medical History and Physical Examination

The process begins with a detailed medical history to identify symptoms and previous infections. A physical examination, including a digital rectal exam, is conducted to identify abnormal openings or tenderness.

Imaging and Diagnostic Tests

Additional diagnostic tests, such as imaging, may be used to accurately assess the fistula and its extent. These can include:

  • Anorectal Ultrasound: Provides detailed images of the fistula tract and surrounding tissues.
  • MRI (Magnetic Resonance Imaging): Provides a comprehensive view of the fistula and any associated complications.
  • Endoscopic Evaluation: This test examines the rectum using a thin, flexible tube and a camera. It allows doctors to see the fistula and how it is connected to the surrounding tissue.

Treatment Options

Non-surgical Treatment

While surgery is often the most effective approach, non-surgical options may be considered in less severe cases.

Antibiotics: Used to treat the infection associated with an anal fistula, antibiotics help reduce symptoms such as pain and swelling but do not cure the fistula itself.

Fibrin Glue: A less invasive treatment for simple fistulas and patients who want to avoid more invasive procedures. The fibrin glue is injected into the fistula tract, sealing it from the inside. This helps to close the fistula and encourages the surrounding tissues to heal naturally.

Surgical Treatment

Surgery is often the most effective treatment for an anal fistula. The goal of surgery is to remove or close the fistula tract to allow proper healing.

Fistulotomy: Commonly used to treat simple anal fistulas that do not involve the anal sphincter muscles extensively. The surgeon cuts open the entire length of the fistula tract, allowing it to heal as a flat scar. Fistulotomy has a high success rate and is effective in preventing recurrence, but it may require a longer healing time.

Seton Placement: Used to treat fistulas involving a significant portion of the anal sphincter muscles to avoid the risk of incontinence. A seton, a surgical thread, is inserted through the fistula tract and tied in a loop outside the body. This keeps the fistula tract open, allowing it to drain gradually and promote healing while minimising sphincter muscle damage.

Advancement Flap Procedure: Used to treat complex fistulas, particularly those involving the anal sphincter muscles. This technique is used when a fistulotomy may result in muscle damage and incontinence.

LIFT Procedure (Ligation of Intersphincteric Fistula Tract): Recommended for complex or recurring fistulas that pass through the anal sphincter muscles. The LIFT procedure involves making an incision in the area between the sphincter muscles (intersphincteric space) to tie off and cut the fistula tract.

Fistulectomy: Reserved for severe cases in which other treatments have failed or when the entire fistula tract must be removed. While this is effective in eliminating the fistula, it carries a higher risk of affecting the anal sphincter muscles, potentially leading to complications such as incontinence. Because of these risks, fistulectomy is typically considered only when other treatments are not viable.

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Preventing Anal Fistulas

Preventing anal fistulas involves addressing their underlying causes and practising good health habits.

Prompt treatment of anal infections and abscesses can help prevent fistula formation. Managing chronic conditions such as Crohn’s disease or ulcerative colitis can also lower the risk.

Maintaining good anal hygiene and a healthy, high-fibre diet can help prevent constipation and reduce the risk of abscess formation and subsequent fistulas.

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Dr. Sulaiman Bin Yusof

MbChB (Sheffield)

M.Med (Surgery)

FRCSEd (General Surgery)

蘇萊曼·尤索夫博士

Dr. Sulaiman Yusof is a distinguished Senior Consultant in colorectal and general surgery, boasting over 15 years of expertise. His passion lies in minimally invasive techniques, particularly robotic surgery, where he has achieved remarkable success using the Da Vinci Xi system. Dr. Sulaiman is dedicated to delivering high-quality, personalized, and empathetic care, always striving for the best outcomes for his patients.

Education & Specialist Training
  • MbChB(Sheffield)
  • M.Med(Surgery)
  • FRCSEd(General Surgery)

Dr. Sulaiman’s journey began at the University of Sheffield, where he graduated in 2002. He honed his skills during his house officer and basic surgical training in the UK before returning to Singapore. There, he completed his Advanced Surgical Training at Changi General Hospital and earned the Joint Speciality Fellowship in General Surgery in 2013.

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    Frequently Asked Questions

    Can I exercise with an anal fistula?

    Moderate exercise is generally acceptable, but activities that put pressure on the anal area, like cycling or heavy lifting, may aggravate symptoms. Low-impact exercises such as walking or swimming are often better choices. Listen to your body and avoid activities that cause discomfort.

    Can an anal fistula recur after treatment?

    Yes, anal fistulas can recur, especially if the underlying cause, such as Crohn’s disease, is not well managed. Recurrence depends on the complexity of the fistula, the treatment used, and overall health.

    Can an anal fistula cause more serious health issues if left untreated?

    Yes, if left untreated, an anal fistula can cause recurring infections, abscesses, and sometimes more complex fistula tracts that are harder to treat. In rare cases, chronic infection can cause tissue damage, and there is also a small risk of developing a more serious condition like anal cancer over time.

    Can children develop anal fistulas, or does it only affect adults?

    While less common, children can develop anal fistulas, often due to an infection in the anal area. Fistulas in children are usually simpler and may resolve with less invasive treatments. However, they should be evaluated by a paediatrician or paediatric surgeon.

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