A fistula is an abnormal tract or passageway that connects two otherwise distinct organs to each other. With anal fistulas, a small tunnel — almost always the result of a previous abscess — connects the anal gland where the abscess occurred to the skin of the buttocks outside the anus. An anal fistula may consist of a single tract or may have several tracts and openings leading in and out of the region.

While anal fistulas can cause discomfort and pain, they are usually related to benign conditions such as anal gland infections and anal abscesses around the anal region. Only in rare cases are they related to more serious conditions such as cancer or Crohn’s disease (a form of inflammatory bowel disease).

If you have an anal fistula

Treatment is recommended as they may sometimes — if the constant inflammation leads to cellular mutation — lead to cancer. Symptoms include constant pain in the anal region that is sometimes accompanied by swelling. Other symptoms include discharge of pus and/or blood and fever, indicating infection of the anal glands. There may also be itchiness or chafing around the anal region.

Risks

Contrary to prevailing belief, anal fistulas are not due to diet, hygiene or anal sex. There is nothing to prevent the condition, which is most common in young men. The severity of a fistula depends on the depth of the patient’s anal glands. The deeper the glands, the more severe the condition tends to be.

Diagnosis

This requires a thorough brief of a patient’s symptoms, medical history and a clinical inspection. Whilst most cases may not need detailed radiological investigations, difficult or recurrent anal fistulas may need further investigation before surgery either to detail their anatomy or to understand if there is any risk to anal continence.

Currently, Video — Assisted Anal Fistula Treatment (VAAFT) may be used to provide a detailed understanding of fistula’s anatomy and to provide treatment without risk of injuring delicate anal muscles which may otherwise result in anal incontinence. This minimally invasive procedure is performed through a scope inserted into the anal fistula.

Treatment

Anal fistulas are usually treated through open surgery. The tract that covers up the fistula is opened up and the overlying skin and muscle is cut or a technique called LIFT (ligation of the Internal Fistula Tract) is used. These techniques allow the fistula to heal from the base of the cut, as the body develops skin to cover the new growth and heal over itself completely. Laying open is usually used for low fistulas only but LIFT may be used for higher fistulas. If the fistula is too complex or deep in the body, other techniques such as a surgical loop — a seton — may be placed through the fistula to allow parts of it to drain before a second surgery is done. Other surgical methods involve use of anal fibrin glue or the insertion of a fibrin plug, a device made from the submucosa tissue of the small intestinal. This fistula plug is positioned from the inside of the anus with sutures and acts as a mesh that allows tissue to grow in it, closing the tract.

These methods, however, do not have good healing rates. I favour using the VAAFT technique due to its simplicity, good healing rates and safety profile as far as prevention of anal muscular injury is concerned. This technique may be repeated if necessary without damaging the anal sphincters.