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Clinical Evaluation
andClassication ofAnal Fistula
“Nowadays, the clinical history too often weighs more than a man.”
Martin H.Fischer
12
Key Concepts
• A stula may be associated with external or
internal openings, pus discharge in the perianal area, or at the time of defecation.
• The purpose of clinical assessment is to detect
the internal and external openings, epithelialized stulous tract, and underlying abscess, if
an y.
• Treating a stula becomes more accessible
and manageable if it is adequately classied.
It enables a surgeon to plan a proper procedure
for better results.
12.1 Introduction
Our understanding of stula is credited to surgeons at St. Mark’s hospital.
• In 1841, Salmon performed an anal stula surgery on Charles Dickens.
• Goodsall outlined the co-relation between the
enteric internal and the cutaneous external
opening.
• Park classied anal stulas explaining the
types and courses they may follow [1].
Treating stula becomes more accessible and
manageable if accurately evaluated and adequately classied. The appropriate assessment of
the stula and its association with the sphincters
are signicant factors for a successful surgery.
12.2 Symptoms
The symptoms are
• Itching around the anus due to pus discharge.
• Continuous throbbing pain that worsens dur-
ing sitting. This is more frequent in an anal
stula associated with an abscess.
• Smelly discharge from or near the anus.
• Presence of an external opening with blood-
stained pus discharge.
• Soiling of the clothes with purulent discharge.
• Fever in the presence of an abscess.
12.3 History
For determining the cause of stula, a detailed history followed by physical examination is essential.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
K. Gupta, Lasers in Proctology, https://doi.org/10.1007/978-981-19-5825-0_12
181
182
12 Clinical Evaluation andClassication ofAnal Fistula
The detailed history should include
• Episodes of previous perianal abscess. If present, the frequency of the episodes and treatment received should be noted.
• History of obstetrics surgical procedure.
• History of Crohn’s disease [2].
• Radiation history to the pelvis [2].
• A detailed sexual history is vital as lymphogranuloma venereum can cause a perianal stula [2].
• The procedural or surgical history in the anorectal area, since a stula may occur after any
surgical procedure.
• A detailed medical history, including tuberculosis, should always be taken.
• A detailed history in case of recurrent stulas,
as it appears at the same anatomic location
after healing of an abscess.
12.4 Clinical Examination
The left lateral posture is the preferred position
for examination. Assess the patient by inspecting
the perianal area. The purpose of clinical assessment is to recognize:
• External opening
• Internal opening
• Fistula tracts
• Underlying abscess, if any
A proper clinical assessment is achieved by
• Inspection
• Palpation
• Digital rectal examination
12.4.1 Inspection
A perianal abscess is characterized by a supercial swelling in the perianal region [3]. The typical complaints of the patient include anal pain,
which may be dull or sharp and may increase in
intensity after defecation or sitting [4]. The local
examination may reveal an erythematous area,
induration, uctuance, scarring, or excoriation. A
small opening with purulent discharge in the
perianal area suggests a stula. Usually, this indicates the external opening of an underlying stula tract.
12.4.2 Palpation
Careful palpation will help to identify the brosed
stula tract and its course. The entire perineum
should be palpated with gentle hands; the external opening may appear as an open sinus or elevated granulation tissue with pus or a
blood-stained discharge. Assess the approximate
distance of the external opening from the anal
verge. Observe whether the external opening is
posterior or anterior to a hypothetical line passing
transversely over the middle of the anus. The
internal opening may appear like an induration,
pit, or groove on palpation. The easiest way to
nd the internal opening is to massage the tract
and look for pus oozing at the anal crypt [3].
12.4.3 Digital Rectal Examination (DRE)
DRE is the key to examining the internal opening
in the case of a stula and an abscess. Use a
gloved nger to examine the anal area. After
lubrication with lignocaine jelly, the nger tip
should be introduced into the anus. A circular
intersphincteric groove is felt when one enters
the anal canal. Note the anal tone at rest as well
as on squeezing the buttocks while the nger is in
the anal canal. Any pain, tenderness, or growth
should be noted as well.
A bidigital assessment of the ischioanal
fossa and the anal canal is done. Palpation
within the anal canal should be done circumferentially up to the anorectal ring to rule out an
abscess. The anorectal ring is felt approximately 4cm above the anal verge, marking the
12.4 Clinical Examination
183
distinction between the anal canal and rectum.
It is an essential landmark in determining the
position of a stula. There may be marked tenderness or bogginess in case of an abscess.
Sometimes, the rectum is full of feces, making
the DRE difcult. The patient should be given
an enema and re-examined.
12.4.3.1 The Internal Opening
Induration at the dentate line at 6 or 12 o’clock
indicates an internal opening. Rarely the internal
opening may be present at other sites. An internal
opening is located according to the site of the
anal glands. Sometimes, a hypertrophied anal
papilla can be noticed around the internal opening. The presence of an indentation or a slight
depression is also a sign of an internal opening. It
might not be easy for a beginner to palpate the
internal opening, but with experience, one
becomes well-versed in palpating it. Goodsall’s
rule is also of great help inlocating the internal
opening.
Locating Internal Opening in Case of an
Abscess
• Press the abscess and look for pus discharge
from the internal opening.
• Inject milk or povidone iodine via the external
opening. It implies a communicating stulous
tract if it emerges from the internal opening.
12.4.4 Proctoscopy
It becomes challenging to perform a proctoscopy
if a stula is associated with an abscess. In the
presence of an abscess, proctoscopy may be very
painful. However, if possible, to conduct, it may
demonstrate pus pouring out from the base of the
crypt, indicating an internal opening. The presence of pus or mucopurulent discharge indicates
an underlying abscess.
12.4.5 Sigmoidoscopy
Sigmoidoscopy should be done if there is a suspicion of any disease like Crohn’s disease, ulcerative colitis, or neoplastic lesion.
12.4.6 Fistula Tract Identication
Identifying the type of stula, its course, and the
internal opening is the primary requisite for managing the stula. Sometimes, the tract does not
open into the anal canal. With the tip of the nger,
one can feel the tract as a hard, brous cord. Try
to assess the possibility of extensions and
abscesses by palpating all the sides. The presence
of multiple external openings is indicative of a
complex stula (Fig.12.1).
Never probe a stula tract in the OPD while
examining the stula. It may be painful and lead
to the formation of a false passage.
12.4.3.2 The External Opening
Once the external opening is seen, it is advisable
to note its position. It is present as a small opening outside the anus with or without visible drainage. The drainage from the opening may be
serous, bloody, purulent, or stained with fecal
matter. Sometimes multiple external openings
may be seen with a single internal opening. The
presence of two internal openings with two external openings indicates a synchronous stula tract.
Fig. 12.1 Multiple external openings
184
Posterior : curved tracts
Tr
n
Anterior : straight tracts
12 Clinical Evaluation andClassication ofAnal Fistula
12.5 Goodsall’s Rule andIts
Clinical Signicance
This rule was accurate in 43% of anterior stulas
and 66.8% of posterior stulas in a study conducted by Cuinas et al. [7]. Cirocco WC et al.
Goodsall’s rule, suggested by David Henry
Goodsall, is the most widely used approach for
evaluating stula clinically [5]. Goodsall’s rule
describes the typical path followed by the stula,
which aids inlocating the internal opening precisely [6]. An imaginary transverse line formed
in the middle of the anal orice divides it into
anterior and posterior halves, describing the stula as anterior and posterior (Fig. 12.2).
According to the rule, an external opening anterior to the transverse line has a straight radial
tract, and a posterior one has a curved tract [6].
observed that Goodsall’s rule accurately describes
the tracts with posterior external openings [8]. It is
incredibly accurate in females, with an accuracy
rate of 97%. This correlates with the ndings that
most of the ducts of the anal glands are present
posteriorly [9]. However, Goodsall’s rule did not
fare well in anterior stulas, with an accuracy of
only 49% [8].
Always remember, Goodsall’s rule is a rule
and not a law. The rule is inaccurate in anterior
external opening stulas. In both sexes, it is more
precise to describe the course of a stula tract
with posteriorly located external openings [5, 8].
12.5.1 Exceptions totheRule
12.6 Classication ofFistula! Why
• An exception to the rule is an external opening
3cm away from the anal verge. The stula in
such cases is always indirect.
• When there are multiple external openings,
the course would be a posterior opening stula
because of branching and intercommunication
between these openings.
• Horseshoe stulas are occasionally connected
with posterior and anterior openings in the
anal canal.
An anal stula can be blind (only internal opening), complete (external and internal openings),
or incomplete (external opening but no internal
opening). Hence, the need to classify stulas
becomes mandatory, which can assist the surgeon
in determining the complexity and simplicity of
the tract. The stula tract location with structures
surrounding the anus and the rectum helps classify the stulas [10]. Classication of stulas
Goodsall’s rule has a diagnostic accuracy of
just 66.9%, according to K Cuinas and JG William.
determines the type of tract, spread, and the
extent of the sphincters involved, making its
implication important both anatomically and
therapeutically. As a surgeon, one should prefer a
classication that enables him to make the right
decisions and aids in adopting the surgical technique. The classication should be predictive,
memorable, and comprehensive.
ansverse anal line
cept of an anorectal ring, which is formed with
puborectalis and the deep portion of the external
anal sphincter, and the importance of its role in
3 cm
maintaining continence [11]. They classied stulas as anal and anorectal, depending on whether
Exceptio
they lie below or above the anorectal ring [11]. In
1961, Goligher modied the classication by
categorizing high anorectal stulas into pelvirectal and ischiorectal. A pelvirectal stula is formed
Fig. 12.2 Goodsall’s rule
when the inammation extends beyond the infra-
Do WeClassify Them?
Milligan Morgan, in 1934, introduced the con-
Tr
Supra - sphincteric
12.7 Park’s Classication
185
levator space by penetrating the infralevator fascia and ischiorectal when the inammation is
limited to the ischiorectal region [11].
Eisenhammer, in 1958, emphasized the role of
the intersphincteric plane in the etiopathogenesis
and progression of stula [10].
In 1959, Steltzner divided stulas into three
categories [11]:
• Intermuscular—present between the conjoined longitudinal muscle and the internal
sphincter.
• Trans-sphincteric—extending beyond the
external sphincter.
• Extrasphincteric—outside the sphincter muscle complex.
12.7 Park’s Classication
Park classied the stula-in-ano into four primary types based on the anatomy and its relationship to the sphincter muscle in a group of 400
patients [10]. This classication is most widely
accepted and extensively used in surgical practice (Fig. 12.3). However, after accumulating
extensive data, the percentage of types of stulas
was changed [10].
Park has classied stula into the following
types [10]:
• Intersphincteric: The stula extends up to
the intersphincteric plane.
• Trans-sphincteric: The stula extends
beyond the external sphincter into the ischiorectal space. It may be low or high, depending
on the extent of the external anal sphincter
involved.
• Suprasphincteric: The stula penetrates
through the intersphincteric plane above the
puborectalis and moves downwards to the
ischiorectal fossa into the skin via a levator
plate.
• Extrasphincteric: The stula tract passes
outside the sphincter complex to enter the
perianal skin from the rectum, passing through
the levator muscle and ischiorectal fat.
12.7.1 Intersphincteric Fistula
The commonest stula is the intersphincteric stula, which originates on the dentate line, passes
through the intersphincteric space, and opens at
the anal verge in the perianal area. The occurrence reported is 45% to 75%. A drained or burst
perianal abscess developing from the infected
anal gland leads to its formation [10, 11]. Fistulas
arising from midline anal ssures are also of
intersphincteric type [12]. In the research work in
1962, Park mentioned that inammation from a
ssure either infects an anal gland or seals off the
ducts discharging into the crypts [10]. If the crypt
gets infected later, an abscess may form and drain
via the anal canal or the intersphincteric region,
thus, making the intersphincteric stulas the most
common. It must be emphasized that the origin of
the abscess lies in the longitudinal muscle and the
internal anal sphincter. Hence it is also known as
an intermuscular stula [13]. An observation
worth mentioning is that in chronic ssures with
sentinel piles, a subcutaneous stula may form
Fig. 12.3 Park’s
classication
Rectum
Extra - sphincteric
tract
Inter - sphincteric
ans - sphincteric
tract
tract
Area of
pectin
tract
Dentate line
186
Conjoined longitudinal
Internal opening
tract
12 Clinical Evaluation andClassication ofAnal Fistula
once the edges of the sentinel piles join, leaving a
raw area underneath.
Intersphincteric stula can be further sub-
classied into different types:
12.7.1.1 A1: Intersphincteric Fistula
withLow Tract
The tract goes down to the anal verge from the
initial abscess in the intersphincteric plane
(Fig. 12.4). This stula represents a perianal
abscess in the acute phase [10]. They are also
referred to as simple low stulas.
12.7.1.2 A2: Intersphincteric Fistula
Having aHigh Blind Tract
The stula between the intersphincteric plane has
a cephalad extension and ends blindly (Fig.12.5).
Fig. 12.4 A1—Intersphincteric stula with
simple low tract
12.7.1.3 A3: Intersphincteric Fistula
withaRectal Opening
This stula extends from the intersphincteric
plane and opens into the rectum. Often these
types of stulas are mistaken for extrasphincteric
stulas. According to Park, one can differentiate
between the two at the time of insertion of the
probe. The probe is palpated near the lumen of
the anal canal when an intersphincteric stula is
present (Fig.12.6).
12.7.1.4 A4: Intersphincteric Fistula
withNo Perineal Opening
The tract goes from the intersphincteric plane
and passes upwards into the rectum. It enters the
gut by a high opening or terminates as a high
blind tract. Often, it is wrongly referred to as a
Fig. 12.5 A2—Intersphincteric stula with
high blind tract
muscle
External anal
sphincter
Inter - sphincteric
High blind
extension
External anal
sphincter
Dentate line
Internal anal
sphincter
Dentate line
Internal anal
sphincter
Conjoined longitudinal muscle
High inter - sphincteric extension
12.7 Park’s Classication
Fig. 12.6 A3—Intersphincteric stula with
rectal opening
High blind tract up
to the rectal wall
High extension
opening into
the rectum
External anal
sphincter
187
Dentate line
Internal anal
sphincter
opening into the rectum
Internal anal sphincter
Fig. 12.7 A4—Intersphincteric stula without perineal opening
submucosal stula [10]. There is no sign of a caudal extension to the perianal area (Fig.12.7).
12.7.1.5 A5: Intersphincteric Fistula
withPelvic Extension
In the acute stages, this variety is more common.
After passing the intersphincteric region, the tract
enters the pelvic cavity, where it lies above the
levator ani muscle (Fig.12.8). No caudal extension exists in the anal verge, and there are no visible stula signs.
12.7.1.6 A6: Intersphincteric Fistula
Secondary toPelvic Infection
The infection from the pelvic disease travels
downwards to reach the intersphincteric plane. It
does not relate to the anal canal, and hence, it is
not an anal stula in the real sense (Fig.12.9).
External anal sphincter
Dentate line
12.7.2 Trans-Sphincteric Fistula
Trans-sphincteric stula extends beyond the
internal and external sphincters that begin at the
dentate line. The incidence reported is 20–29%
[10]. The level of the tract determines the sphincter complex involvement. It may be uncomplicated or complicated.
12.7.2.1 B1: Uncomplicated
The tract enters the ischiorectal fossa from the
intersphincteric plane, passes across the external
sphincter, and nally opens into the skin [10]
(Fig.12.10). It is classied as high or low depending upon the extent of the sphincter involved. It is
low when less than 30% external anal sphincter is
involved and high when more than 30% of the
external anal sphincter is involved [14].
188
Conjoined longitudinal muscle
Internal anal sphincter
Internal anal sphincter
Inter - sphincteric tract
with pelvic extension
External anal sphincter
Fig. 12.8 A5—Intersphincteric stula with pelvic extension
12 Clinical Evaluation andClassication ofAnal Fistula
Dentate line
Inter - sphincteric tract with no
Fig. 12.9 A6—Intersphincteric stula secondary to pelvic infection
communication
with the anal canal
External anal sphincter
Dentate line
Tr
Conjoined longitudinal
into the supralevator
sphincter
12.7 Park’s Classication
Fig. 12.10 B1—Uncomplicated
189
Upward extension
into the ischio
rectal fossa
Conjoined longitudinal
muscle
Internal anal
External anal
sphincter
ans - sphincteric
tract
muscle
Dentate line
Internal anal
sphincter
Upward extension
space
External anal
sphincter
Dentate line
Fig. 12.11 B2 complicated (High blind tract and tract with extension toward pelvis)
12.7.2.2 B2: Trans-Sphincteric Fistula
Associated withtheHigh
Blind Tract
The tract crosses the external sphincter and
across the puborectalis and levator ani muscles.
The tract forms a loop above the entire sphincter
complex. Such stulas are reported in 1% to 3%
of cases (Fig.12.12).
divides into two, giving a lower and an upper
extension. The lower tract passes to the perianal
skin, but the upper extension may go to the apex
12.7.4 Extrasphincteric Fistula
of the ischiorectal fossa or cross the levator ani
muscle (Fig.12.11) [15].
The external opening of these stulas is present
in the perianal skin, while the internal opening is
above and outside the sphincter complex [10].
12.7.3 Suprasphincteric Fistula
Before entering the ischiorectal fossa, the stula
begins in an intersphincteric plane and passes
Between 1% and 2% of such cases have been
recorded (Fig.12.13).
Park has classied the extrasphincteric stula
based on its pathogenesis:
190
Conjoined longitudinal
Conjoined longitudinal
sphincter
Fig. 12.12 Suprasphincteric tract
12 Clinical Evaluation andClassication ofAnal Fistula
Supra - sphincteric
External anal
Fig. 12.13 Extrasphincteric tract
Extra - sphincteric
External anal
12.7.4.1 Extrasphincteric Fistula
Resulting fromTransSphincteric Fistula
Trans-sphincteric stula associated with a high
blind tract allows the infection to reach the levator and the rectal wall. It can be iatrogenic or
spontaneous. This stula may develop from:
• The cryptoglandular infection, or
• High intrarectal pressure causing contamina-
tion of the rectal opening
12.7.4.2 Extrasphincteric Fistula
Resulting fromTrauma
Infection may occur as a result of:
tract
muscle
sphincter
tract
muscle
Dentate line
Internal anal
sphincter
Dentate line
Internal anal
sphincter
12.7.4.3 Extrasphincteric Fistula
DuetoSpecic Anorectal
Diseases
Diseases like Crohn’s, ulcerative colitis, and carcinoma may cause stula-in-ano [10].
12.7.4.4 Extrasphincteric Fistula
asaConsequence ofPelvic
Inammation
The infection from the gut may spread downwards through the pelvis and the levator ani and
penetrate the perineum [10].
12.8 Simple andComplex Fistula
• A foreign body enters the rectum via the
perineum, causing rectal contamination and a
subsequent stula.
• An ingested foreign body (i.e., a shbone)
might end up in the rectum [10].
Another classication subdivides stulas into
simple and complex [16].