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A A
Ravi P. Kiran
bscesses in the anorectal region occur in all age groups and are a
common, distressing problem. Predisposing factors include dia-
A
betes, Crohn disease, previous perianal surgery, and impairment of
immunity, including human immunodeciency virus (HIV); however,
most abscesses occur spontaneously in healthy persons. Diagnosis is
usually established by clinical examination, and adequate drainage
is the treatment of choice. Drainage results in healing in more than
half of cases. Persistence or recurrence is due to inadequate drainage,
predisposing factors, or a stula in ano.
Based on a study of patients treated for anorectal abscesses at Cook
County Hospital and followed up for a 35-month period, Read and
Abcarian reported in 1979 that the peak incidence was in the third
decade, with males aected 1.76 times more frequently than females.
e most common abscess in this series was perianal (42%), followed by
ischiorectal in 20% and supralevator in 7%. An anal stula could be demonstrated in 34% of patients. A subsequent report from Cook County
Hospital in 1984 conrmed a similar relative frequency of anorectal
abscesses (42.7% perianal, 22.7% ischiorectal, 21.4% intersphincteric,
and 7.3% supralevator). Intersphincteric and supralevator abscesses had
a higher incidence of concomitant stula. Other study investigators have
also found that the perianal variety is the most common and the intersphincteric variety is most commonly associated with a stula in ano.
A brief review of the anatomy of the spaces surrounding the anorectum (Fig. 4-1) helps in the understanding of the etiology, pathways
of the spread of infection, and clinical presentation, all of which have
a bearing on the management of anorectal abscesses.
SURGICAL ANATOMY
e perianal space surrounds the anus and becomes continuous with
the fat of the buttocks. e intersphincteric plane separates the external and internal sphincter muscles, is continuous with the perianal
space, and extends superiorly into the rectal wall. Anal glands are
found in the intersphincteric plane, traverse the internal sphincter,
and empty into the anal crypts at the dentate line. Lateral to the anus
is the ischiorectal space, which is bounded superiorly by the levators,
medially by the external sphincter, laterally by the ischial tuberosity,
and inferiorly by the transverse perineal septum. e two ischiorectal fossae are connected posteriorly through the deep postanal space
between the levators and the anococcygeal ligament. e supralevator space lies superior to the levator ani on either side of the rectum.
ETIOLOGY
e cryptoglandular theory, which states that sepsis originates in the
anal glands because gland openings in the crypts are blocked, is the most
widely accepted explanation for the development of anorectal abscesses.
e glands extend into the surrounding sphincter muscles, and when
infection is present, sepsis extends to a variable extent into and between
these muscles and tracks along lines of least resistance. e ndings of
one study in the United Kingdom suggest that patients with stula in ano
in addition to an abscess are more likely to have gut aerobes (predominantly Escherichia coli) or gut-specic anaerobes (Bacteroides fragilis)
isolated from the pus than are persons without stulae.
NATURAL HISTORY OF THE DISEASE AND SPREAD PATHWAYS
e intersphincteric plane is involved rst, leading to an intersphincteric abscess. Spread of infection in a downward direction leads to
presentation as a perianal abscess. When pus penetrates the external
sphincter below the puborectalis and enters the ischiorectal fossa, it may
point further laterally as an ischiorectal abscess. From here, pus may
track into the postanal space and into the opposite ischiorectal space,
leading to the formation of a horseshoe abscess. Upward extension of
intersphincteric sepsis results in a supralevator abscess. Abscesses may
enlarge and burst spontaneously in the perianal or ischiorectal area or
into the rectum. Once drained, the infection usually settles, but occasionally a stula develops, which may lead to a recurrent abscess.
CLINICAL FEATURES
e cardinal clinical signs of inammation described by Celsus (i.e.,
rubor [redness], calor [warmth], dolor [pain], and tumor [swelling]),
along with the additional sign of Virchow (i.e., functio laesa [diculty in sitting down and painful defecation]), are usually present.
Patients sometimes present with a partially burst abscess, and persistent residual sepsis and examination may reveal induration. Physical examination ndings depend on the location of the abscess and
associated disease.
Perianal Abscess
Most abscesses in the anorectal region are perianal abscesses, which
are seen in 40% to 45% of patients. Patients present with constant
perianal pain and a localized swelling. Examination reveals an erythematous, tender swelling adjacent to the anus with varying amounts
of induration, cellulitis, and uctuance. Rectal examination usually
does not demonstrate any uctuance or tenderness above the dentate
line. Some patients may not have a uctuant swelling—just erythema.
Ischiorectal Abscess
An ischiorectal abscess presents further laterally than a perianal
abscess, in the region of the ischiorectal fossa. Because there is more
room for the abscess to expand in this area, it may present as a diuse
21
AnorectAl Abscess22
s
Internal sphincter
External hemorrhoids
Valves of Houston
Columns of Morgagni
Puborectalis
Conjoined
longitudinal muscle
Deep
Subcutaneous
Superficial
External
sphincter
FIGURE 4-1 Anatomy of the anal canal. (From Gordon PH. The anorec-
tum: anatomic and physiologic considerations in health and disease. Gastro-
enterol Clin North Am. 1987;16:2.)
Internal hemorrhoid
Dentate line
Anal crypt
Anal gland
Submucosal Abscess
Submucosal abscesses come from high intermuscular abscesses and
may present aer rupture into the rectum. Symptoms may include a
dull ache with a sense of fullness in the rectum. e only nding may
be a tender, smooth, submucosal swelling.
DIAGNOSIS
Diagnosis of anorectal abscesses is mostly clinical. Patients usually
present with perianal pain and swelling. A discharge of blood and pus
indicates a spontaneous rupture. Fever and painful defecation may be
present. Clinical examination usually reveals a tender, erythematous
swelling that may be uctuant. Supercial abscesses are obvious, whereas
deep sepsis produces a general swelling and asymmetry of the area. Aspiration with a wide-bore needle may conrm the diagnosis. Aspiration
is performed aer induction of general anesthesia, at which time anoscopy and proctoscopy help rule out Crohn disease and may identify the
Anal canal
internal opening of a stula. HIV and carcinoma also can be excluded.
Imaging modalities including intrarectal ultrasound, computed tomography, and magnetic resonance imaging have been reported to be useful
adjuncts in diagnosis, especially for deep or complex abscesses. Dierential diagnosis of anorectal abscesses includes hidradenitis suppurativa,
pilonidal abscess, tuberculosis, and actinomycosis.
swelling in the gluteal region. e abscess may extend posteriorly to
communicate with the opposite ischiorectal fossa, forming a horseshoe abscess. e deep anterior anal space also may be involved.
Intersphincteric Abscess
e relative incidence of this variety of anorectal abscess is 2% to 5%.
Intersphincteric abscesses were rst described by Eisenhammer and
subsequently divided into high and low types. Symptoms and signs
are similar to those of other anorectal abscesses, but ndings are not
as prominent. Patients report dull anal or rectal pain and occasionally may present with a high temperature. A sense of fullness in the
rectum and painful defecation may be present. Mucus discharge from
the anus also may occur. Usually no external ndings are present,
but upon rectal examination, exquisite tenderness and swelling may
be present in the region of the abscess. Adequate examination may
be precluded by pain. Intersphincteric abscesses are most commonly
associated with stulae and also are most likely to recur.
Supralevator Abscess
Supralevator abscesses are uncommon, with an incidence ranging from
2.5% to 9.1% in dierent studies. A supralevator abscess results from
the upward spread of infection from an intersphincteric abscess or a
downward spread of infection from diverticulitis or pelvic inammatory disease. e presentation is similar to an intersphincteric abscess,
and diagnosis is dicult because of the absence of signicant local
ndings. Symptoms include a dull, aching, rectal pain accompanied by
fever with chills. Urinary symptoms may be present as a result of local
pressure eects. Digital rectal examination may suggest the presence
of an abscess or diuse anorectal fullness. Imaging usually plays an
important role in the diagnosis of this variety of abscess.
Deep Postanal Abscess
Patients with a deep postanal abscess present with anal pain and tenderness but have no swelling. Digital examination reveals a fullness
posteriorly, just above the sphincters.
Treatment of Anorectal Abscesses
Anorectal abscesses should be drained. Goligher initially advocated
incision, curettage, antibiotic instillation, and primary closure. e
traditional method of treatment involves deroong by means of a cruciate incision followed by loose packing of the abscess cavity. Because
the acidic medium of pus reduces the eectiveness of local anesthetic
agents, induction of general anesthesia may be required for adequate
drainage. An alternate procedure that is particularly useful in the
oce setting is the placement of a catheter into the abscess through
a small incision at the site of maximal pointing, which obviates the
need for an extensive skin incision and can be performed with use
of a local anesthetic. Satisfactory results were reported by Isbister in
1987 and by Beck etal in 1988.
A cruciate incision is made over the site of pointing, and the skin
edges are trimmed to prevent premature closure of the skin. e resulting cavity is either loosely packed with iodoform gauze or alternatively drained with a 10 to 16 French mushroom or de Pezzer catheter.
Patients are advised to use sitz baths with regular dressings, and followup is performed in the oce. If a drain is placed, it is removed aer 7 to
10 days, depending on the size of the cavity. Catheter drainage is safe,
convenient, and well tolerated by patients and compares favorably with
the more traditional method of treating anorectal abscesses.
Large Abscesses
For large abscesses where catheter drainage may be ineective, multiple counterincisions are connected with a Penrose drain sutured onto
itself. is procedure minimizes the discomfort and problems with
wound management of a long open incision and prevents deformity of
the perianal tissues that may occur with healing of an extensive wound.
Searching for a Fistula
If the abscess is the rst instance of perianal sepsis, no search for a
stula is undertaken. e odds favor a simple abscess with no recurrence. If it is a recurrent abscess, then a gentle probing can be performed to determine if a stula is present. A false track should not be
created. If an intersphincteric or transsphincteric track leading to the
ANAL AND PERIANAL REGION 23
internal opening is present, it should be drained with a vessel loop
seton. If a subcutaneous stula is identied, incision and drainage of
the abscess is combined with a primary stulotomy.
Ischiorectal Abscess
Ischiorectal abscesses are managed in the same manner as perianal
abscesses. Concomitant involvement of the deep anterior or posterior
anal spaces and horseshoe abscesses can be managed through use of
counterincisions. Deep anterior or posterior anal space abscesses are
managed by performing a staged stulotomy involving placement of
a seton to minimize division of sphincter muscles. Advancement ap
repair is an alternative. Horseshoe abscesses are managed by draining the postanal space and placing bilateral counterincisions in the
ischiorectal fossae.
Intersphincteric Abscesses
Intersphincteric abscesses are treated through use of an internal
sphincterotomy because this procedure deroofs the abscess, permitting drainage. e mucosa at the site may need to be sutured to establish hemostasis.
Supralevator Abscess
e cause of a supralevator abscess needs to be identied because
optimal management depends upon dealing with the source of infection. Supralevator abscesses originating from cephalad spread of a
perianal or ischiorectal abscess are drained by means of an initial
internal sphincterotomy exposing the abscess cavity, which may
in turn be drained into the rectum. Extensive abscesses and those
originating from a pelvic source such as diverticulitis or inammatory bowel disease may need to be drained through the rectum or
ischiorectal fossa or by computed tomography–guided transabdominal drainage. Patients with persistent and complex supralevator
abscesses may sometimes need a colostomy or ileostomy, especially
when inammatory bowel disease is present.
Submucosal Abscess
Submucosal abscesses are managed by means of drainage into the
rectum.
Role of Antibiotics and Biopsy
Previous work by Goligher and Ellis, conrmed by Wilson and most
recently by the results of a randomized controlled trial, suggest that
antibiotic therapy is not routinely indicated for treatment of anorectal
abscesses in healthy persons. Antibiotics are needed in immunocompromised and diabetic patients and in persons with cardiac prostheses. e need for extensive debridement at the time of drainage and
the presence of residual surrounding cellulitis are also indications for
use of antibiotics. A culture of pus and a biopsy of the cavity wall are
performed for persistent or recurrent sepsis. A biopsy also may be
indicated at the time of the initial drainage of the abscess if Crohn
disease or neoplasia needs to be ruled out.
Postoperative Care
Aer drainage of pus, regular dressings and sitz baths are used.
Laxatives help prevent constipation and reduce the eort and pain
of defecation. If recurrence or a stula develops, examination with
use of an anesthetic and treatment of the abscess or stulotomy is
indicated.
Complications
Urinary retention is a common complication aer operations for
benign anorectal conditions, including abscesses. Severe disease,
older age group, and use of perioperative uids were identied as risk
factors in a study at the Mayo Clinic.
RECURRENCE AND THE DEVELOPMENT OF FISTULA IN ANO
Hamalainen and others followed up on patients who underwent drainage of anorectal abscesses over a period of 99 months and found that a
stula developed in 37% and a recurrent abscess developed in 10%. In
the study at Cook County Hospital alluded to earlier in this chapter, it
was found that patients who underwent abscess drainage alone had a
recurrence rate of 3.7%, whereas those who underwent a simultaneous
stulotomy had a lower recurrence rate of 1.8% during a mean followup duration of 36 months. Chrabot and colleagues studied anorectal
abscesses prospectively and noted that causes for recurrence included
insucient prior treatment (68%), wrong diagnosis (hidradenitis suppurativa), and missed components. Vasilevsky and Gordon reported
that in 11% of patients with perianal or ischiorectal abscesses, a recurrent abscess develops, whereas persistent stula in ano develops in
37% aer isolated drainage of anorectal abscesses. ey advocated the
policy of selective secondary stulotomy based on these results because
more than half of all patients with anorectal abscesses are cured with
a simple drainage of anorectal abscess. Schouten and van Vroonhoven
compared primary stulectomy with drainage alone for perianal
abscesses in a randomized controlled trial and also reported a similar
combined persistence or recurrence rate (40.6%) aer isolated abscess
drainage over a median follow-up period of 42.5 months. Recurrence
was lower, but disturbances of anal function were higher in the stulectomy group than in the isolated drainage group. e authors also advocate reserving stulectomy as a second procedure to obviate the risk
of anal functional disturbances in the remaining 60% of patients. In
contrast, other investigators recommend that a primary stulotomy be
performed at the time of drainage of perianal abscesses as the preferred
treatment to minimize occurrence of persistent stulas because their
series showed no added risk of fecal incontinence.
S u g g e S t e d R e a d i n g
Beck DE, Fazio VW, Lavery IC, et al. Catheter drainage of ischiorectal ab-
scesses. South Med J. 1988;81:444–446.
Corman ML. Colon and Rectal Surgery. 2nd ed. Philadelphia: JB Lippincott; 1989.
Goligher JC. Surgery of the Anus, Rectum and Colon. 5th ed. London: Balliere
Tindall; 1984.
Hamalainen KP, Sainio AP. Incidence of stulas aer drainage of acute ano-
rectal abscesses. Dis Colon Rectum. 1998;41:1357–1361.
Ho YH, Tan M, Chui CH, etal. Randomized controlled trial of primary s-
tulotomy with drainage alone for perianal abscesses. Dis Colon Rectum.
1997;40:1435–1438.
Isbister WH. A simple method for the management of anorectal abscess. Aust
N Z J Surg. 1987;57:771–774.
Read DR, Abcarian H. A prospective study of 474 patients with anorectal ab-
scess. Dis Colon Rectum. 1979;22:566–568.
Schouten WR, van Vroonhoven TJ. Treatment of anorectal abscess with or
without primary stulectomy. Results of a prospective randomized trial.
Dis Colon Rectum. 1991;34:60–63.
Sözener U, Gedik E, Aslar AK, etal. Does adjuvant antibiotic treatment aer
drainage of anorectal abscess prevent development of anal stulas? A ran-
domized, placebo-controlled, double-blind, multicenter study. Dis Colon
Rectum. 2011;54:923–929.
Vasilevsky CA, Gordon PH. e incidence of recurrent abscesses or stula-in-
ano following anorectal suppuration. Dis Colon Rectum. 1984;27:126–130.
A F
Mark L. Manwaring
INTRODUCTION
An anal stula is an abnormal communication between the inside
of the anus and epithelium outside the anus. e most common
anal stula is an anocutaneous stula, which is the subject of this
chapter.
ETIOLOGY
Anal glands have an opening in the anal crypts that are found at the
dentate line. Infection in these glands spreads into the intersphincteric space, and from there it passes between or though the sphincters
to reach the skin. e infection usually presents as an abscess, which
drains spontaneously or by incision, leading to the potential for a stula. e stula connects the internal opening (the gland opening at
the dentate line) with the site of external drainage (the external opening). Aside from anal cryptoglandular infection, other causes of anal
stulas are Crohn disease, anorectal neoplasms, trauma, and mycobacterial or fungal infections.
CLASSIFICATION
Anal stulas are classied according to their relationship to the anal
sphincter complex (Table 5-1). Persistence of the tract results in a
chronic cycle of contamination through the internal opening, seeding the tract with pus, which drains intermittently from the external
opening. e tendency of the external opening to seal results in inadequate drainage with recurrent abscesses and even the development
of multiple external openings. It also contributes to the chronicity of
the process.
PRESENTATION
Few patients with anal stulas are truly asymptomatic; however,
the risks of treatment should be balanced against the severity of
symptoms. Identication of a stula does not mandate repair, and
a long-term indwelling seton is an option to minimize symptoms in
patients for whom denitive repair may be risky or result in poor
function. However, in most cases, when exacerbations of infection
occur, repair should be recommended. e decision about how to
treat a stula should take into consideration the patient’s comorbid
conditions, the potential underlying cause of the stula, and the morbidity of treatment.
DIAGNOSIS AND EVALUATION
Careful attention to the patient’s history of perianal infections and
symptoms can oen suggest the diagnosis of a stula, which is usually conrmed by examination. Symptoms include intermittent pain,
blood-tinged perianal drainage, skin irritation, moisture, pruritus,
soilage or seepage, and recurrent abscesses. It is critical to assess continence and obtain a thorough history, including obstetric experiences
and bowel function. Patients with pre-existing anorectal dysfunction,
chronic diarrhea, or inammatory bowel disease require particularly
cautious treatment to avoid incontinence and recurrence.
e dierential diagnosis of anal stulas includes hidradenitis
suppurativa (usually distinguished by the multiple supercial scars
in the area and the lack of an internal opening at the dentate line), a
simple epidermal inclusion cyst, a skin infection such as a boil, and
pilonidal disease. In women, drainage from a Bartholin gland infection may mimic the external opening of an anal stula.
An external opening that appears to be chronic is suggestive of
a stula. When palpable induration leading toward the anal canal is
noted, a stula is highly likely. Discomfort during examination and
deep anal crypts may preclude identication of the internal opening
in the oce, but purulent drainage from a visible internal or external opening oen conrms the diagnosis. Imaging studies are not
routinely used because in the vast majority of cases, examination
under anesthesia allows identication of the tract and treatment
without the extra expense and delay entailed in obtaining imaging
studies.
Routine antibiotic therapy has little role in the management of an
anal stula. Antibiotics are indicated when a patient has associated
cellulitis, or for patients with immunosuppression, diabetes, recent
TABLE 5-1: Parks Classification of Anal Fistula
Parks Classification Involvement Illustration
Intersphincteric Internal sphincter only Figure 5-2
Transsphincteric Internal, supercial external sphincter Figure 5-3
Suprasphincteric Internal, external sphincter, puborectalis Figure 5-7
Extrasphincteric Entire sphincter complex Figure 5-8
24
ANAL AND PERIANAL REGION 25
implants, valvular heart disease, or prostheses. Metronidazole is oen
used for patients with perianal Crohn disease, although data to support this practice are limited. e use of postoperative antibiotics
aer stula repair is common, but this practice has not been shown
to aect outcome.
Preparation and Examination
No routine preoperative laboratory evaluations are mandatory except
for an electrocardiogram in patients older than 45 years; consideration may be given to obtaining a blood cell count or blood chemistry
panel in patients with comorbidities. Preparation of the anal area
with use of an iodine or chlorhexidine solution is routine but does
not sterilize the stula tract or the rectum. Use of a Foley catheter is
not necessary. e initial examination aer induction of anesthesia
can be performed with the patient in the lithotomy position. Denitive treatment of posterior tracts is easiest with the patient in the
lithotomy position, whereas in patients with anterior internal openings, treatment is easiest with the patient in the prone position.
Aer the patient has been anesthetized, the external opening is
gently probed with an appropriately sized blunt probe, taking care
to avoid creation of false passages. Having a nger in the anal canal
helps dene the direction of the tract. If the probe does not exit
through the internal opening, anoscopy during injection of the tract
with saline solution, methylene blue, or hydrogen peroxide can help
identify a patent internal opening. e type of anoscope used (e.g.,
Bivalve or Hill-Ferguson) depends on the surgeon’s preference, but
adequate lighting is facilitated by scopes with an integral ber-optic
light source or use of a headlight. With use of these maneuvers, an
instrument can almost always be guided through the stula tract.
Creation of false openings or tracts should be avoided. Once the tract
is identied, its anatomy can be dened and it can be categorized
according to Parks classication (see Table 5-1). When the anatomy
is unclear or if a probe cannot be passed through an irregular tract,
magnetic resonance imaging (MRI) or ultrasound can be helpful.
Management decisions can then be made with these data in light of
the patient’s specic comorbidities and clinical presentation.
For recurrent stulas or complex tracts, particularly in patients
with Crohn disease, or when a supralevator source is suspected based
on oce examination, high-resolution MRI or computed tomography
(CT) may be considered preoperatively to assist in surgical planning,
patient counseling, and intraoperative guidance. Fistulography oers
a less complete evaluation but may help in localizing the connection
of perineal stulas to abdominopelvic processes or may assist the surgeon when the tract cannot be identied intraoperatively.
TREATMENT
A general management algorithm for anal stulas is presented in
Figure 5-1.
INTERSPHINCTERIC ANAL FISTULA
Clinical Findings
An intersphincteric stula (Fig. 5-2) typically has an external opening relatively close to the intersphincteric groove, near the anal verge.
is feature can oen be helpful in providing preoperative counseling
about the type of procedure most likely to be performed before the
diagnosis is denitively made at the time of surgery. e tract will lie
parallel to the long axis of the anal canal before traversing the internal
sphincter near the dentate line, typically deep in a crypt. Palpation of
the tract should reveal that it consists of skin and anoderm, hemorrhoidal tissue, and the lower end of the internal sphincter.
Treatment
Treatment consists of laying open the stula tract, usually aer injection of a local anesthetic for postoperative analgesia and hemostasis.
Minimizing cautery minimizes delay in healing. e brous base of
the tract is curetted but le intact and the edges are shelved to help
Fistula suspected Persistent drainage
Office exam, H and P
informed consent
Exam under
anesthesia
Intersphincteric tract
Low transsphincteric
tract
High transsphincteric
tract
Suprasphincteric
tract
Extrasphincteric
tract
Fistulotomy
Draining
seton
Establish drainage
Treat supralevator
Pathology
Drainage of
perianal abscess
LIFT
or
advancement flap
Healing
FIGURE 5-1 General management
algorithm. LIFT, Ligation of the
intersphincteric fistula tract.
AnAl FistulA26
Puborectalis
Dentate line
Puborectalis
Levator
External
Internal
sphincter
FIGURE 5-2 An intersphincteric fistula (the shaded portion is divided
with a fistulotomy).
sphincter
healing occur by secondary intention. All tissue is sent for histologic
evaluation. Any supercial extensions of the stula tract should be
unroofed at the time of the stulotomy.
In a related though less common scenario, a patient has no visible external opening and the intersphincteric abscess has extended
proximally toward the supralevator location. In such cases it would be
reasonable to place a drain transanally in the defect and obtain crosssectional imaging with CT or MRI to identify any supralevator abscess.
is uncommon condition can then later be treated with an endoanal
advancement ap and drainage through the intersphincteric plane.
Incontinence Risk
In most cases, performing a stulotomy to treat an intersphincteric
stula results in a cure and does not aect continence. However,
in a recent series of patients treated with a stulotomy for intersphincteric stula, changes in continence occurred in 30 of 148
patients (20%). Incontinence was minor in most patients, with atus incontinence accounting for nearly three fourths of the cases.
is possibility should be discussed preoperatively, and patients
with recurrent disease and poor sphincter tone may have a better
outcome with an alternative procedure (such as a cutting seton or
an advancement ap).
TRANSSPHINCTERIC ANAL FISTULA
Clinical Findings
e external opening of a transsphincteric stula (Fig. 5-3) is typically located over the ischiorectal fossa at least 2 cm from the anal
verge, and the tract usually follows an angled course toward the anal
canal. Most stulas follow Goodsall rule, with radial tracts for anterior external openings and curved tracts to the midline posteriorly
for posterior openings. Low transsphincteric stulas involve only the
most supercial bers of the external anal sphincter, but high transsphincteric stulas incorporate more than one third of the external
anal sphincter (EAS) within the tract. Dierentiating the two types
of stulas can be a challenge in the setting of acute inammation
and induration without ultrasound imaging, and the implications for
continence may be signicant if the assessment is incorrect. Anterior stulas may include a higher percentage of the external sphincter
because of the normal thinning of the EAS in this area, particularly
in women. Transsphincteric lesions in the posterior midline may
involve the deep postanal space, which can secondarily result in
External
sphincter
FIGURE 5-3 A transsphincteric fistula (the shaded portion is divided if
a fistulotomy is performed).
communication to the ischiorectal spaces through bilateral tracts.
Careful examination of the internal opening in the posterior midline should be performed to conrm unilateral involvement because
occult contralateral tracts can cause recurrent infection.
In light of the involvement of the EAS with transsphincteric tracts,
decisions regarding treatment must be made with consideration of
the patient’s preoperative anorectal functional status. e anatomic
relationships of the tract, gender of the patient, surgical history, and
any relevant underlying conditions also must be considered.
Treatment
Posterior or lateral low transsphincteric tracts in patients at low risk
for incontinence are best treated with a stulotomy. Healing ensues
with a low risk for recurrence whether or not marsupialization
sutures are used for the edges. A cutting seton can be used for low
transsphincteric stulas to minimize the risk of even minor degrees
of incontinence.
Cutting Seton
When a cutting seton is used, the tract is identied and evaluated.
e skin and anoderm are then divided down to the muscle, leaving the muscle intact. e skin edges are trimmed and a vessel loop
seton is tied tightly around the muscle. As long as the anoderm has
been divided, this maneuver will not cause pain. e patient is seen
in the oce a week later, and at that time the seton is tightened using
hemorrhoid bands. e tightening is repeated weekly until the seton
erodes through the muscles and falls out. e idea behind use of a
cutting seton is that brosis keeps the ends of the divided muscle
close together so less functional impairment occurs.
Sphincter-Preserving Techniques
Anterior and high transsphincteric stulas and transsphincteric stulas in patients with borderline continence should be treated with
sphincter-preserving techniques. Sphincter-sparing techniques for
repair include ligation of the intersphincteric stula tract (LIFT), use of
an endoanal advancement ap, and use of a stula plug. A partial stulotomy preserving the involved external sphincter also can be performed.
LIFT
e LIFT technique (Fig. 5-4) was rst described by Phillips and
colleagues in 1993 and was brought to the fore again in 2007 by
Rojanasakul etal. It has become more widely accepted during the
ANAL AND PERIANAL REGION 27
of internal
External opening enlarged
Intersphincteri
fistula tract
Suture ligation
c
Plane of
dissection
FIGURE 5-4 Ligation of the intersphincteric fistula tract.
Approximation
of muscles
with running
absorbable
suture
Closure of incision
TABLE 5-2: Selected Published Ligation of the Intersphincteric Fistula Tract Outcomes
Follow-up
Study N Study Type
Rojanasakul etal, 2007 18 Prospective Up to 26 wk 17/18 (94)
Bleier etal, 2010 39 Retrospective 20 (2-38) wk 20/35 (57)
Ellis, 2010 31 Retrospective 15 (12-30) mo 29/31 (94)
Shanwani etal, 2010 45 Prospective 9 (2-16) mo 37/45 (82)
Median (Range) Healing (%)
Suture
closure
sphincter
Suture
ligation
Abcarian etal, 2011 24* Prospective 18 (2-64) wk 16/21 (76)
Aboulian etal, 2011 25 Retrospective 24 (8-52) wk 17/25 (68)
Sileri etal, 2011 18 Prospective 6 (4-10) mo 15/18 (83)
Tan etal, 2011 93 Retrospective 23 (1-85) wk 80/93 (86)
Han etal, 2012 21 Retrospective 14 (12-15) mo 20/21 (95)
Mushaya etal, 2012
†
25 Randomized 16 (8-31) mo 22/24 (92)
Ooi etal, 2012 25 Prospective 22 (3-43) wk 10/25 (40)
Wallin etal, 2012 93 Retrospective 19 (4-55) mo 37/93 (40)
van Onkelen etal, 2013 22 Prospective 20 (3-35) mo 18/22 (82)
*Patients with irritable bowel disease were excluded.
†
Only patients with ligation of the intersphincteric stula tract are represented.
past decade as increasing experience with the technique has underscored a good success rate and a favorable pattern of failure when it
occurs (Table 5-2). e technique has become the standard approach
for transsphincteric lesions when sphincter preservation is desired.
Key to the technique is the presence of a mature brous tract. To
obtain such a tract, any purulence is drained, a draining seton is
placed through the stula, and denitive surgery is delayed for at
least 6 weeks until the stula tract has matured and surrounding
inammation has resolved. e external opening is opened widely
within the external sphincter. e tract is divided between the ligatures and hydrogen peroxide is used to conrm that the tracts have
been sealed. Using a running suture, the muscle is imbricated over
the closure sites while the potential intersphincteric space is closed
from deep to supercial. e skin is closed with interrupted ne
polyglactin or gut sutures. Most surgeons prescribe antibiotics postoperatively. LIFT may be applied to recurrent stulas, but as with
most procedures, better results are achieved with primary stulas.
for drainage. An incision is made over the intersphincteric groove,
and dissection is carried through the intersphincteric space to and
around the stula tract aided by prior placement of a probe through
the tract. Use of a Lone-Star retractor facilitates exposure. Suture
ligation of the tract at the deep surface of the internal sphincter
muscle is performed with polyglactin sutures with a second ligation
ADVANCEMENT FLAP
Advancement ap repair of anal stulas (Fig. 5-5) has been the standard technique for sphincter-sparing stula repair since the early
1980s. Preparation should include simplication of the tract, drainage
AnAl FistulA28
n
a
Divided muscl
sphincter and puborectalis
Internal
opening at
dentate line
Dentate line
Anal verge
FIGURE 5-5 Advancement flap repair.
of any associated collections, and resolution of related inammation,
usually by placement of a draining seton for a minimum of 6 weeks. A
partial-thickness ap of mucosa, submucosa, and some muscle with a
width of about 2 to 3 cm is created at a site of healthy tissue beginning
distal to the stula. is ap is taken proximal for at least 4 to 8 cm,
creating a tongue of tissue with a base wider than the apex. e length
should be sucient for a tension-free extension of the ap over the
stula opening. e stula tract is cored out from within the internal
sphincter muscle and excised. e internal sphincter is approximated
with interrupted absorbable sutures, and the ap is brought over this
closure and sewn in place. Wide drainage of the external stula opening is critical to prevent sepsis within the tract from draining through
the repair. Advancement ap repair can be used for failed LIFT repairs
or for prior failed aps, albeit with somewhat lower success rates.
A large number of studies have been reported, with success rates
ranging from 24% to 100%. A recent review of 1654 cases from published reports showed an average overall success rate of 78.1%. Lowlevel data predominated and important data, including incontinence
rates, were oen omitted, but when they were reported, they ranged
from 3% to 35%. Even with recent popularization of the LIFT procedure, the ap repair remains the procedure of choice for many surgeons for transsphincteric stulas.
PARTIAL FISTULOTOMY
Performing a partial stulotomy by dividing the internal sphincter
and overlying anoderm distal to the internal opening (Fig. 5-6) eectively drains the intersphincteric space. For high transsphincteric
lesions, the external sphincter muscle can be preserved and a draining seton can be le in the portion of the tract within the external
sphincter. is seton is removed aer adequate healing—typically in
6 weeks. Although this approach is associated with an acceptable success rate, when these residual stulas through the external sphincter
fail to heal, options are limited. A LIFT cannot be performed, and a
ap repair may cause signicant ectropion. A stulotomy may be the
only option available to correct the stula at this point.
SUPRASPHINCTERIC ANAL FISTULA
Externally, the appearance of a suprasphincteric anal stula (Fig. 5-7)
may be identical to that of a transsphincteric lesion. However, when
probing shows a tract extending well above the dentate line, a suprasphincteric stula must be suspected. is stula may not be suspected
in women with a short anal canal, so particular care must be taken to
accurately identify the anatomy. e intersphincteric sepsis in this setting spreads cephalad to the junction of the puborectalis and external
sphincter muscle before traversing the muscular complex. Subsequent
spread through the ischiorectal space leads to drainage through the
external opening. Palpation may reveal induration at the level of the
levators, suggesting this type of high tract.
Fistula tract
cored out
and closed
Dentate line
Anal verge
Levator
e
FIGURE 5-6 A partial fistulotomy with a draining seton for an anal
fistula.
Excised portio
with prior fistul
Anal verge
Preserved external
If the internal opening cannot be identied intraoperatively, adequate external drainage should be provided and interval ultrasound or
MRI should be requested. e internal opening is usually still near the
dentate line, and advancement ap repair remains the most commonly
used technique for repair. e LIFT technique also may be possible in
select patients depending on the length of the anal canal. Establishing
good drainage, usually with placement of a draining seton, is a key rst
step in management. A stulectomy with removal of the entire tract,
primary closure internally, and wide drainage externally has also been
reported with reasonable success. With the additive success of all these
techniques, even most intransigent suprasphincteric stulas can be corrected without dividing signicant portions of the sphincter complex.
However, if these other techniques are not options, division of the internal sphincter muscle below the level of the stula and placement of a
draining seton around the external muscle aer division of the most
supercial bers of the external anal sphincter can allow the infection to
resolve, and eventually the draining seton can be removed. Fecal incontinence, soiling, and atus incontinence will be common if signicant
portions of the external anal sphincter are divided during this process.
Fistula Plugs
Fistula plugs oer another sphincter-sparing alternative for treatment
of stulas in patients at high risk for incontinence. e potential exists
for healing with a low-risk procedure, and plugs should be considered
in patients with simple, long, mature tracts without undrained sepsis.
Facilitation of healing with a simple procedure makes stula plugs an
attractive option, although the results are oen disappointing.
EXTRASPHINCTERIC ANAL FISTULA
Internal openings located above the levators are uncommon, but
when they are present, they indicate the presence of an extrasphincteric stula; the entire sphincter complex is surrounded by the
Puborectali
s
Supralevator abcess
r
FIGURE 5-7 A suprasphincteric fistula.
ANAL AND PERIANAL REGION 29
Pelvic abcess
Levato
stulous tract (Fig. 5-8). is situation may result from creation of
a false passage, meaning that the patient now has two stulas—the
original stula and the one just created by the surgeon. Alternatively,
Crohn disease, diverticulitis with abscess erosion, malignancy, an
anastomotic leak aer pouch-anal anastomosis, or low colorectal
anastomosis may cause an extrasphincteric stula. If the stula is
from the sigmoid colon without associated rectal communication,
a sigmoid colectomy provides source control, and healing can be
expected. More generally, correction of the supralevator disease will
eliminate the source of the infection. When the source of the stula
is the rectum, however, repair may be more challenging, particularly
in light of the underlying disease that typically exists in these rare
instances (i.e., Crohn disease). Options for these complex situations
include sleeve resection, an endorectal advancement ap, or a longterm indwelling seton. Fibrin glue and stula plug techniques also
may be used with a low expectation of success.
Crohn Disease
In light of the underlying causative disease, a stulotomy usually
should not be performed in persons with Crohn disease except to
treat the most supercial stulas because of progressive dysfunction
related to recurrent stulas at other locations. Placement of draining
setons and treatment of proctitis is the rst step. With successful resolution of proctitis, a standard approach to repair is generally taken,
albeit with somewhat inferior results.
Deep Postanal Space Abscess with a Horseshoe Fistula
Key to the treatment of a horseshoe stula is control of the deep postanal space sepsis with adequate drainage. Lateral tracts will then heal
if they are adequately drained. In the 1960s, Hanley described placing
a probe in the posterior causative anal crypt and opening the skin and
subcutaneous tissues in a straight line toward the tip of the coccyx.
is procedure involved division of the subcutaneous external anal
sphincter and splitting of the “V”-shaped posterior directed bers of
the supercial external sphincter. e internal muscle distal to the
dentate line was also divided. Counterincisions at the lateral extent
of the ischiorectal tracts, usually with draining setons or unroofing, allow for adequate drainage. Subsequently, midline cutting and
SPECIAL SITUATIONS
FIGURE 5-8 An extrasphincteric fistula.
placement of lateral draining setons with tract debridement, which
some persons refer to as the “modied Hanley procedure,” was suggested. Alternatively, a draining seton can initially be placed to control the posterior midline infectious source and an interval ap repair
can be performed to close the internal opening.
SUMMARY
Key principles of anal stula management include identifying the
tract, understanding its anatomy, controlling sepsis, simplifying the
tract, and identifying and closing the internal opening. Careful counseling can establish realistic goals and expectations, especially for
patients with complex stulas. Functional implications should be discussed preoperatively so that whatever the outcome, the patient can
participate appropriately in the informed consent process and cope
with the results of surgery, which are usually favorable.
S u g g e S t e d R e a d i n g
Ellis CN. Outcomes with the use of bioprosthetic gras to reinforce the liga-
tion of the intersphincteric stula tract (BioLIFT procedure) for the management of complex anal stulas. Dis Colon Rectum. 2010;53:1361–1364.
Garg P, Song J, Bhatia A, etal. e ecacy of anal stula plug in stula-in-ano:
a systematic review. Colorect Dis. 2010;12:965–970.
Parks AG, Gordon PH, Hardcastle JD. A classication of stula-in-ano. Br J
Surg. 1976;63:1–12.
Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva K. Total
anal sphincter saving technique for stula-in-ano; the ligation of intersphincteric stula tract. J Med Assoc ai. 2007;90:581–586.
Soltani A, Kaiser AM. Endorectal advancement ap for cryptoglandular or
Crohn’s stula-in-ano. Dis Colon Rectum. 2010;53:486–495.
Sonoda T, Hull T, Piedmonte MR, Fazio VW. Outcomes of primary repair of
anorectal and rectovaginal stulas using the endorectal advancement ap.
Dis Colon Rectum. 2002;45:1622–1628.
ia KT, Mahadevan U, Feagan BG, etal. Ciprooxacin or metronidazole for
the treatment of perianal stulas in patients with Crohn’s disease: a randomized, double-blind, placebo-controlled pilot study. Inamm Bowel Dis.
2009;15:17–24.
Toyonaga T, Matsushima M, Kiriu T, et al. Factors aecting continence
aer stulotomy for intersphincteric stula-in-ano. Int J Colorect Dis.
2007;22:1071–1075.
van Onkelen RS, Gosselink MP, Schouten WR. Ligation of the intersphinc-
teric stula tract in low transsphincteric stulae: a new technique to avoid
stulotomy. Colorect Dis. 2013;15:587–591.
van Onkelen RS, Gosselink MP, Schouten WR. Treatment of anal stulas with
high intersphincteric extension. Dis Colon Rectum. 2013;56:987–991.
R F
Tracy Hull
DEFINITION
Any communication between the rectum/anus and the vagina/perineal skin is classically referred to as a rectovaginal stula (RVF). RVF
is an accepted term for any stula that originates in the distal rectum
and anus and is connected to the vagina, perineal body, or labial area,
because the evaluation and treatment are similar. In contrast, a stula
between the colon and vagina (such as may occur aer a hysterectomy when the sigmoid communicates with the top of the vagina)
is a completely dierent problem and will not be discussed in this
chapter.
CAUSES
An obstetrical injury is the most common cause of RVF. Other
common causes are cryptoglandular sepsis, Crohn disease, cancer,
radiation therapy, and trauma (e.g., aer excision of a mass in the
rectovaginal septum). Identifying the source of the stula is critical
because it may alter the evaluation and treatment plan.
HISTORY AND PHYSICAL EXAMINATION
Obtaining an accurate history is important, beginning with an exact
description of symptoms. Passage of gas, stool, or purulent uid
and the presence of dyspareunia, perineal pain, vaginal irritation,
and recurrent urinary tract infections should be noted. e patient
should describe her bowel habits both before and aer the symptoms
started, including a complete description of fecal incontinence. e
eect of the symptoms on daily life is important. Other factors that
aect bowel habits such as chronic diseases (e.g., diabetes, lupus)
and all medications should be reviewed. e patient’s radiation, pelvic/anal surgery, and obstetrical history is noted, and in preparation for surgery, a full medical and surgical history is obtained and
a review of systems is performed. Box 6-1 outlines specic areas to
be covered.
During the physical examination, the abdomen is evaluated for
body habitus, scars, hernias, and masses. Any debris at the vaginal
introitus should be noted at the beginning of the perineal examination. Particular attention is directed to the status of the anus (i.e.,
closed or open), the width of the perineal body, and the movement
of the anal muscle when the patient is asked to strain and squeeze.
A more detailed evaluation of the vagina is performed next; one
should look for the actual vaginal opening, the presence of stool in
the vagina, and any prolapse of the vaginal wall with straining. e
rectovaginal septum is critically appraised with a nger in the anus
and a nger in the vagina, feeling for induration or a sense of fullness. During the digital anal examination, the anal tone at rest and
30
while squeezing along with early fatigue (i.e., reduced strength of anal
contractions during several repetitive squeezes) is assessed. Recruitment of buttock muscles when the patient is asked to squeeze versus
levator contraction versus actual anal muscle contraction is noted,
along with the presence of masses, stool in the rectum, and induration (particularly anteriorly). At times the internal opening of the
stula can actually be felt during the digital examination. e shape
of the upper medial thighs should be noted because gas or stool can
escape the anus and pass forward into the vagina, later to be expelled,
suggesting a stula. In such cases the patient does not have a stula,
of course, and instruction in the management of anal incontinence
is provided. Patients with loose upper thighs are prone to this phenomenon because the anatomy directs the seeping material forward
toward the vagina.
e next step is anoscopy and proctoscopy (either exible or rigid)
to seek the internal opening of the stula and to note the condition
of the rectal and anal mucosa. Noting the presence of anal or distal
rectal ulceration at the internal opening is important because repair
is avoided when inammation is present. Sometimes rigid or exible endoscopy of the vagina provides valuable information regarding
the size and location of the stula and assists in visualizing debris in
the vagina. If the completeness of the examination is in question, an
examination is performed aer the induction of anesthesia to fully
delineate the size and location of the stula. Another benet of performing an examination aer the patient has been anesthetized is that
it provides the opportunity to drain any trapped sepsis by unroong
a cavity or placing a draining seton. Before any repair can be entertained, all sepsis must be eliminated so the tissue is as so and supple
as possible. If the cause of the stula is related to cancer, liberal biopsies of the area are performed to rule out recurrence.
Other testing depends on ndings uncovered during the history
and physical examination. Any women older than 50 years should
have a colonoscopy. Other indications for a colonoscopy include a
history of loose stool, the possibility of Crohn disease, or a change in
stool habits. Areas of inamed mucosa or other lesions are biopsied.
Additionally, random biopsies are performed in women with diarrhea to rule out microscopic colitis. Diarrhea and irritable bowel–
type symptoms may warrant a consultation with a gastroenterologist.
Bowel habits should be optimized prior to plans for surgical repair of
the stula. Also, if Crohn disease is proven or suspected, a complete
bowel evaluation is benecial because medical therapy or surgery
may be included in the treatment algorithm.
e role of anal physiology testing in the workup of a patient with
an RVF is debated. Such testing should only be performed if the caregiver believes it would alter the treatment approach. In contrast, anal
endosonography is overall probably the most benecial test because
it provides full details regarding sphincter integrity, which inuences
the choice of surgical procedure.
Aer all data are gathered, treatment is proposed. When discussing treatment with the patient, realistic goals should be elucidated.