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Part III
Diagnosis of Fistula and Abscess
Anorectal Physiology Assessment in Patients with Anal Fistula: When Necessary
9
Alessandro Sturiale
, Bernardina Fabiani, Felipe Celedon Porzio,
Luigi Brusciano, Claudia Menconi, and Gabriele Naldini
Contents
1 Introduction . ............... .................................................................. 130
2 Anorectal Physiology Assessment ..................... ..................................... 130
2.1 Anamnesis . ........................................................................ .... 131
2.2 Physical Examination ... . . . . ...... . . . . . ....... . . . . ....... . . . . ..... . . . . . . ....... . . . . ... 131
2.3 Anorectal Manometry ..................... .................................. .......... 131
2.4 Neurophysiologic Tests ............................................................... 133
2.5 Endoanal Ultrasound ... . . . ...... . . . . ...... . . . . .... . . . . . ...... . . . . ...... . . . ...... . . . . .. 134
2.6 Role of Anorectal Physiology Patterns in the Decision-Making ..................... 135
3 Discussion . ..... . . . . ...... . . . . ....... . . . ..... . . . . . ...... . . . . ...... . . . . ...... . . . . ...... . . . . ... 135
References ............................ ............................................... ............ 138
Abstract
An anal fistula is an abnormal communication between the anal canal and perianal
skin through a channel coated by epithelium. Surgical treatment is the gold standard
approach to achieve anal fistula healing exploiting many different techniques available according to clinical conditions and surgeon’s experience. Independently from
A. Sturiale (*) · B. Fabiani
Proctology and Pelvic Floor Clinical Centre, Cisanello University Hospital, Pisa, Italy
F. C. Porzio
Department of Coloproctological Surgery, Hospital de la Fuerza Aerea de Chile, Santiago de Chile, Chile
Proctology and Pelvic Floor Clinical Centre, Cisanello University Hospital, Pisa, Italy
L. Brusciano
Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania “Luigi
Vanvitelli”, Naples, Italy
C. Menconi · G. Naldini
Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania “Luigi
Vanvitelli”, Naples, Italy
Proctology and Pelvic Floor Clinical Centre, Cisanello University Hospital, Pisa, Italy
© Springer Nature Switzerland AG 2022
C. Ratto et al. (eds.), Anal Fistula and Abscess, Coloproctology,
https://doi.org/10.1007/978-3-030-76670-2_11
129
130 A. Sturiale et al.
the success rate of each technique, it is fundamental an adequate preoperative
counseling with the patient, explaining not only the fistulizing disease but also the
whole condition of the anorectal complex which influences the postoperative functional results. In this context, anorectal physiology evaluation may play a role,
starting from anamnesis and physical examination until specialistic diagnostic investigations such as anorectal manometry, electromyography for the anorectal function,
and tridimensional transanal ultrasound to assess sphincter anatomy. Hence, in
selected patients it is recommended the anorectal physiology preoperativeassessment
making the patients aware of their own conditions and helping the surgeon to choose
the best surgical approach considering also the subsequent functional outcomes.
Keywords
Physiology assessment · Anorectal manometry · Electromyograph · Endoanal
ultrasound · Nerve conduction studies
1 Introduction
An anal fistula is an abnormal communication betw een the anal canal and perianal
skin through a channel coated by epithelium. Its overall incidence is about 2/10,000
people per year (Sainio 1984; Zanotti et al. 2007), and in more than a third of
patients, it is a consequence of an acute anorectal abscess (Amato et al. 2020).
Surgical treatment is the gold standard approach to achieve anal fistula healing
exploiting many different techniques available according to clinical conditions and
surgeon’s experience.
As well as for other surgical procedures (i.e., anterior rectal resection for low
rectal cancer), the surgeon needs to solve the main problem preventing or limiting
the likelihood of postoperative functional sequelae which may affect healed patients
for a long-lasting period or even for the whole life.
Moreover, even in the case of a technically correct surgical procedure with an acceptable outcome (organic and functional) from the surgeon’s point of view, the patients
frequently perceive as self-limiting minor functional sequelae. This difference existing
between the surgeon and the patient needs to be filled with long and accurate preoperative
counseling, thus preventing also postoperative claims of compensation for unavoidable
consequences, taking into consideration the anatomic and functional preoperative situation.
For these reasons anorectal physiology assessment in patients affected by anal
fistula might become helpful to clearly define sphincter anatomy and anorectal
function helping the surgeon to explain and predict the postoperative anatomic and
functional outcome according to the specific surgical procedure chosen.
2 Anorectal Physiology Assessment
Anorectal physiology evaluation has its hinge in the anamnesis and physical examination. After the first visit, further investigations might be considered as preparatory
to subsequent surgery for anal fistula whose counseling was already done with the
9 Anorectal Physiology Assessment in Patients with Anal Fistula: When... 131
patient. Specialistic diagnostic investigations were anorectal manometry (ARM),
electromyography (EMG) for the anorectal function, and tridimensional transanal
ultrasound (3D-TAUS) to assess sphincter anatomy whose evaluation can be completed, if necessary, using pelvic magnetic resonance imaging (MRI).
2.1 Anamnesis
During this initial step, it is important to investigate coexistent symptoms which may
be hidden by the main disease or the patient does not underline them because his
attention is focused on anal fistula and its related bother symptoms.
The knowledge of preoperative symptoms independent from anal fistula is
particularly relevant to avoid the mistake to correlate postoperative symptoms to
surgery instead of preoperative disease.
The conventional questions are about the time interval of symptoms appearance,
their frequency, and impact on the patient’s life (working, social and sexual life). It is
worth to know the age of patients with personal habits, type of work, hobbies, and
sociocultural status thus taking stock according to his/her own expectations.
Moreover, it is necessary to assess stool consistency using a validated scale as the
Bristol stool scale (Blake et al. 2016;O’Donnell et al. 1990) and correlate it to the
presence of diarrhea, constipation, or regular bowel.
2.2 Physical Examination
The three steps of proctologic physical examination are inspe ction, digital exploration, and anoscopy if feasible. Excluding the anal fistula evaluation (type, site,
length, internal orifice width, and presence of abscess), physical examination gives
further information that help to reach a complete anatomo-functional evaluation.
Through the inspection the proctologist may appreciate ano-perianal scars and
anal profile which may be regular or deformed by previous surgery or trauma.
Digital exploration allows to assess the anal tone (resting, squeezing, and
straining) and anal muscles with possible deformation and focal trigger points.
Anoscopy, when feasible, gives information about internal hemorrhoids and
internal rectal prolapse.
2.3 Anorectal Manometry
ARM allows an evaluation of the whole anal sphincter complex. It provides a
comprehensive anal sphincter and rectal function assessment measuring the following parameters: resting pressure (RP), squeeze pressure (SP), cough reflex (CR),
recto-anal inhibitory reflex (RAIR), and rectal sensitivity (RS). All of this information may help in the diagnosis of preoperative disorders, confirming the physical
examination, and also in further surgical planning.
132 A. Sturiale et al.
Although standard practice guidance about how to perform ARM was published
(Azpiroz et al. 2002; Rao et al. 2002), it still lacks a real test standardization shared
by the community. Moreover, a recent international survey assessing ARM practice
clearly revealed that all the centers involved from 30 different countries used sundry
protocols for all the phases of the procedure lacking global uniformity. Indeed, there
is not a single center which fully complied with published guidelines (Carrington
et al. 2017). These evidences reduce the test credibility, its reproducibility to
compare data from different referral centers. and also their interpretation for clinical
purposes.
Despite conventional ARM is still used in many centers, in the last years, it was
registered a shift toward high-resolution technology allowing to record and display
at the same time detailed information of the whole anal canal and distal rectum
(Carrington et al. 2017; Dinning et al. 2015).
ARM assesses different functions of the anorectal unit through a number of
predefined maneuvers during the examination. All the parameters analyzed needed
to be listed inside the final reports should be:
– Anal resting tone
– Squeezing tone, to assess anal contractility
– Straining pressures (anal and rectal) to investigate the coordination during
defecation
– Anorectal reflex in response to cough maneuver
– Anorectal inhibitory reflex
– Rectal sensitivity (first sensation, constant sensation, and maximum tolerated
volume)
2.3.1 Equipment
ARM equipment consists basically of four components which are (Scott and
Gladman 2008):
– Pressure catheter for the measurement
– Transducers that may be external or inside the catheter;
– A balloon to be inflated inside the rectum
– Recording system with dedicated software varying from factories
The transduction system can use the solid-state, water-perfused, or air-charged
systems. The high-resolution technology may be feasible only with the solid and
water perfused while the 3D high-resolution only with the solid-state equipment
(Scott 2019).
2.3.2 Manometry Systems
For each type of catheter, there is a dedicated software to acquire and display in
different ways, from multiple pressure lines to a 3D colored topographical model of
the anal canal that can be rotated and analyzed from all sides.
9 Anorectal Physiology Assessment in Patients with Anal Fistula: When... 133
For the high-resolution (HR)-ARM, three systems are available: ManoScan™
AR manometry system (Medtronic), Solar GI manometry system (Laborie), and the
InSIGHT manometry system (Medimar).
There are also portable manometric systems such as mCompass (Medspira) or
Anopress (THD Worldwide). These systems use air-charged catheters allowing to
perform the investigation easily in any place but HR-ARM is not feasible through
such systems (Scott 2019).
2.4 Neurophysiologic Tests
2.4.1 Electromyography
Electromyography (EMG) is a neurophysiologic investigation to assess motor unit
components in neuromuscular diseases, including also pelvic floor diseases as anal
incontinence or defecation disorders (Rosato and Lumi 2005). Firstly introduced by
Piper in 1908 (Piper 1908), EMG records the electrical activity that muscle fibers
generate at rest and during contractions (Adrian and Bronk 1929).
Different electrodes may be used to record muscle activity such as surface
electrodes, concentric needle electrodes, and wire electrodes (Swash 2002).
The purpose of EMG in the assessment of pelvic floor disorders is to determine
the following items:
– Muscle fiber denervation/reinnervation
– Sphincter integrity
– Voluntary muscle contraction and relaxation
EMG can be used in association with anamnestic and clinical data and other
investigations to get the best patient assessment, thus proposing adequate treatment.
However, at present it has been superseded by other pelvic floor studies due to local
discomfort.
In fact, according to the recent American Society of Colon and Rectal Surgeons
(ASCRS) guidelines, EMG has a low impact upon the diagno sis and further management of patients affected fecal incontinence. For these reasons, it is not routinely
recommended but suggested in selected cases (Paquette et al. 2015).
2.4.2 Nerve Conduction Studies
Nerve stimulation investigations or conduction testing may be used in association
with EMG. Among these there is pudendal nerve terminal motor latency (PNTML),
pudendal somatosensory evoked potentials (pSEPs), perineal sympathetic skin
response (pSSR), and perineal motor evoked potentials (pMEPs).
PNTML technique was used at first by Kiff and Swash in 1984 (Kiff and Swash
1984). It consists of the transrectal stimulation of the pudendal nerve bila terally to
measure conduction speed along the terminal portion of the nerve with the patient in
the left lateral position. The 0.1 msec stimulus is repeated with a 1 s interval. The
normal latency reference value is up to 2.2 msec (Rosato and Oliveira 2020).
134 A. Sturiale et al.
However, its diagnostic value and sensitivity have been recently questioned because
of doubts over its feasibility and reliability (Bianchi et al. 2017).
The two main causes of pudendal nerve injury are (Rosato and Oliveira 2020):
• Acute stretching during labor or chronic straining
• Chronic stretching due to long-lasting constipation with straining and descent
perineum
pSEPs ares used to assess the integrity of the somatosensory afferent pathways
from the pudendal nerve to the parietal cortex.
pSSR provides information about the sympathetic sudomotor activity analyzing
skin conductance changes after peripheral nerve electrical stimulation.
pMEPs are based on transcranial magnetic stimulation to evaluate the motor
efferents to the pelvic floor muscles. Anyway, studies investigating the role of
pMEPs in patients with neurological disorders are fairly heterogeneous.
2.5 Endoanal Ultrasound
Endoanal ultrasound (EAUS) was first described in 1989 by Law et al. (Law and
Bartram 1989), identifying a correlation between the anatomical parts of the anal
canal and the ultrasound images. Over the years the technology improved the quality
of ultrasound images and new tools became available to achieve a more accurate
evaluation of anorectal diseases.
Generally, ultrasound equipment has circular transducers which may be
bidimensional (2D) and tridimensional (3D), whose viewing angle varies from
180 to 360 degrees (Rosato and Oliveira 2020). BK ultrasound (B-K Medical,
Herlev, Denmark) has a high multifrequenc y, 360
a radial electronic probe. The rotational transducer allows a 3D cube acquisition
avoiding probe movements and artifacts. After cube recording, the 3D image may be
rotated and sliced to check different planes and measuring distance, area, and angles
if necessary. There are also tools to change the transparency known as volume
rendering (Santoro et al. 2011).
During examination, the patient may be placed in a dorsal lithotomy, left lateral or
prone position. Independently from the position, the probe should be rotated to
obtain a constant image with the anterior part of the anal canal in the upper side of the
image.
Although EUAS has a predominant role in the diagnosis and classification of the
suppurative anorectal disease considering abscesses and fistulas, in this chapter it
will be considered the other side of anal evaluation in a patient with anal fistula. It is
always extremely important to report after EUAS both evaluations: anatomy of the
anal canal with sphincters (internal and external) and fistula features.
One of the most relevant utilities of EAUS application is to detect localized
sphincter defects (Burnett et al. 1991; Sentovich et al. 1998; Sultan et al. 1993)
which may be not easily identified through the physical examination.
rotational mechanical probe, or
9 Anorectal Physiology Assessment in Patients with Anal Fistula: When... 135
However, it has been suggested that even if sphincter thickness measurement is
important, it could not depict any sphincter damage showing only diffuse structural
sphincter changes and inhomogeneous aspect (Tjandra et al. 1992; Zetterstr öm et al.
1999).
Finally, 3D-EAUS has been defined as the gold standard imaging investigation
for the evaluation of anal sphincter defects evaluation by the International Consultation on Incontinence (ICI), International Continence Society (ICS), and International Urogynecological Association (IUGA) (Bliss et al. 2013; Haylen et al. 2010).
Starck classification (Starck et al. 2006) is recommended to describe the condition
of sphincters and the presence of gap. It is a scoring system which ranges from 0 to
16, and it is generally used for anal sphincter injures after delivery, but it remains
very useful to define the preoperative sphincter complex situation.
Hence, 3D-EAUS becomes particularly relevant in those patients affected by anal
fistula because in the preoperativ e investigation, using the same necessary exam to
classify the fistula itself, it is possible to define the sphincter anatomy showing, for
example, muscular erosion, misdiagnosed or underestimate obstetric laceration, or
thinning areas related to previous surgery. All these information help the surgeon to
plan the surgical procedure after adequate counseling with the patients.
2.6 Role of Anorectal Physiology Patterns in the Decision-Making
The pathologic patterns of different anorectal physiology investigations and their
impact on the concomitant anal fistula management are resumed in Table 1.
It is important to underline that very often there is not an isolated single pathologic
pattern but concomitant multiple alterations identified with different investigations
assessing anatomy and function. This is the reason why there is an overlapping of
recommended management of patients with anal fistula and other concomitant
anorectal disorders.
In those patients in which a sphincter-saving procedure (SSP) is recommended,
with weak and thin sphincters that needed reinforcement, fistulotomy and reconstruction should be considered as a valid alternative to the conventional flap.
In the case of identification of signs of neuropathy, it should be considered as an
alarm bell for latent future problems, but, to date, it is not considered as something
that may change alone surgical indication.
Another element requiring the surgeon ’s attention is the reduction of the rectal
sensation threshold because it might suggest and irritable bowel syndrome (UBS)
whereby it needs to be investigated and eventually considered in surgical management.
3 Discussion
Anorectal physiology assessment represents a wide chapter of the coloproctologic
functional investigations whose aim is to evaluate the anorectal function and its
related diseases. Usually, these exams are performed in those patients referred to our
136 A. Sturiale et al.
Table 1 Therapeutic options according to preoperative anorectal physiology evaluation
(anamensis and strumental investigations)
Therapeutic strategy
Anamnesis
Passive incontinence SSP with sphincter reinforcement +/ regenerative
Active incontinence SSP +/ rehabilitation +/ NSM
Both
ODS
3D-EAUS
IAS and EAS partial-thickness
gap
IAS and EAS full-thickness gap
IAS partial-thickness gap
IAS full-thickness gap
EAS partial-thickness gap
EAS full-thickness gap
ARM
Normal values No limitations
Low resting pressure
Low squeezing pressure
Dyssynergia No limitations
Low rectal sensitivity threshold SSP +/ rehabilitation. Investigate IBS
Nerve conduction studies
Signs of neuropathy No limitations
SSP, sphincter-saving procedures; NSM, neurosacral modulation; 3D-EAUS, tridimensional endo-
anal ultrasound; ARM, anorectal manometry; IAS, internal anal sphincter; EAS, external anal
sphincter; IBS, irritable bowel syndrome
therapies
According to the fistula – no limitations
SSP with sphincter reinforcement +/ regenerative
therapies
SSP with sphincter reinforcement +/ regenerative
therapies
SSP +/ regenerative therapies
SSP +/ rehabilitation
center complaining anal incontinence or constipation with obstructed defecation.
Sometimes, in case suspicious of concomitant neurologic disease whose main
manifestation is the anorectal disorder, neurophysiologic tests are performed as
complementary to the conventional functional investigations.
However, these tests might be suggested in patients suffering from anal fistula
with associated particular conditions such as:
– One or more fistula recurrence, especially if the previ ous surgical procedures are
performed in other hospitals. In this case the preoperative assessment has a
double aim: clinical to define the preoperative condition helping the surgical
planning. The second, instead, is related to the legal medi cine issue. In fact, it is
not rare that the last surgeon trying to close the fistula became the first to be
involved in the lawsuit.
– Previous obstetric injury with evident or occult-related symptoms.
– Preoperative impaired anal continence.
– Preoperative ODS-related symptoms.