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Nonoperative therapy for hemorrhoid disease
Kerry Hammond and Charles B Whitlow
CHALLENGING CASE
A 50-year-old male, otherwise healthy, presents to your office and
after evaluation is diagnosed with grade 3 internal hemorrhoids.
Rubber band ligation is performed and is well-tolerated. Fortyeight hours later he develops urinary retention and worsening
anal pain.
CASE MANAGEMENT
The patient’s symptoms are suggestive of pelvic or postbanding sepsis. The patient should be examined urgently, admitted,
started on broad-spectrum intravenous antibiotics, and intravenous fluids. A foley catheter should be placed and blood work
(CBC, metabolic profile, etc) obtained. A CT scan of the abdomen and pelvis should be considered. If the initial exam (including anoscopy) is not adequate or demonstrated necrotic perianal
tissue, the patient should receive an exam under anesthesia and
debridement of any necrotic tissue.
INTRODUCTION
“Hemorrhoids” are among the most frequent presenting complaints of patients evaluated in the outpatient setting by colon and
rectal surgeons. In a 1990 review of data from the National Center
for Health Statistics, Johanson and Sonnenberg determined a 4.4%
prevalence of symptomatic hemorrhoids in the U.S. population.(1)
In a subsequent study of data collected by the National Hospital
Discharge Survey, the same authors found that the annual number
of surgical hemorrhoidectomies performed in the United States
had decreased from a peak of 117 per 100,000 patients in 1974 to
a nadir of 37 per 100,000 in 1987.(2) This decrease in operative
procedures is likely the result of improvements in nonoperative
therapies for symptomatic internal hemorrhoids.
Table 18.1 Grading system for internal haemorrhoids.
Grade Physical Characteristics
I Prominent hemorrhoidal vessels without prolapse
II Prolapse with valsalva; reduce spontaneously
III Prolapse with valsalva; manual reduction needed
IV Prolapsed hemorrhoids that cannot be reduced
examination is necessary to differentiate hemorrhoidal disease
from other pathological processes.
Bleeding is the most common symptom associated with
internal hemorrhoidal disease. Patients who have bled secondary to hemorrhoids typically describe painless bleeding which is
bright red in color. This usually occurs with defecation, and may
be limited to the appearance of blood on toilet tissue.(8) More
severe bleeding may result in dripping of blood or even pulsatile
bleeding into the commode.
Hemorrhoidal prolapse can cause a sensation of incomplete
emptying or mucous discharge. Patients with a significant degree
of prolapse often complain of pruritis and difficulty maintaining
anal hygiene.
Physical examination should include a thorough visual and
digital inspection of the perianal soft tissue and anorectum to rule
out conditions such as fissure, abscess, and neoplasm. Anoscopy
can be performed in the office setting and is useful to determine
the extent of hemorrhoidal enlargement. Colonoscopy should be
considered for evaluation of bleeding if indicated by age, family
history of colorectal cancer, or other risk factors for colorectal
cancer.(7, 8, 10)
TREATMENT
ANATOMY AND PATHOPHYSIOLOGY
Hemorrhoids are cushions of vascular and connective tissue located
in the subepithelial space lining the anal canal. Arteriovenous sinusoids between the terminal branches of the superior rectal arteries
and the superior, middle and inferior rectal veins are encompassed
by these cushions. These sinusoids lack a muscular wall, predisposing them to bleeding.(3–5) Hemorrhoidal prolapse develops as
the supportive connective tissue matrix is compromised by age
and trauma.(6, 7)
A simple grading system has been widely adopted for the clinical assessment of symptomatic internal hemorrhoids. This 4-part
grading system can be used by clinicians to describe the extent of
a patient’s pathology and to differentiate which treatment options
are appropriate (Table 18.1). (4–12)
CLINICAL EVALUATION
It is not uncommon for patients to attribute any anorectal discomfort to hemorrhoids. Therefore, a careful history and physical
Conservative Management
The goal of medical management is to provide symptomatic relief
by reducing straining during defecation and thereby eliminating
the repetitive trauma that contributes to hemorrhoidal congestion and prolapse.
Dietary modification is the cornerstone of conservative management for symptomatic hemorrhoids. A diet high in fiber (20–30 g/
day) promotes the formation of soft, formed stool that requires
less straining to eliminate. In a 2006 meta-analysis, Alonso-Coello
et al. evaluated the impact of supplemental fiber on symptoms
related to hemorrhoids.(13) This analysis included 7 studies in
which 378 total patients had been randomized to fiber or nonfiber
controls. Pooled analysis for overall improvement in symptoms
demonstrated a 47% risk reduction of persistence of symptoms
for patients randomized to fiber supplementation. Four studies that addressed bleeding as an individual outcome showed a
combined 50% relative risk reduction in the fiber treatment arm.
(14–17) No significant difference between treatment and placebo
nonoperative therapy for hemorrhoid disease
arms was found in three studies that addressed hemorrhoidal
prolapse.(14, 15, 17)
Supplemental fiber can be delivered in several forms. Resistant
starches, found in legumes and grains, are polysaccharides that are
resistant to a-amylase digestion. Fermentation by colonic bacteria with consequent increases in colonic gas production can produce abdominal bloating and flatulence. Soluble fiber dissolves in
water and produces a viscous solution in the gastrointestinal tract.
Sources of purified soluble fiber include psyllium (Metamucil®,
Konsyl®), inulin (FiberChoice®), pectins, and Methylcellulose
(Citrucel®) a semisynthetic soluble fiber that is not fermented by
colonic bacteria. Insoluble fiber passes largely unaltered through
the gastrointestinal tract with minimal fermentation in the colon.
Natural sources of insoluble fiber include foods such as dark leafy
vegetables and whole wheat products. Calcium polycarbophil
(Fibercon®) is a synthetic bulking agent with properties similar
to those of insoluble fiber.(18, 19)
While allergic reactions to the active or inactive ingredients
in dietary fiber supplements are rare, patients may experience
variable levels of adverse effects such as abdominal bloating and
flatulence after incorporating these products into their daily diet
regimen. A period of gradual dosage increase or trial-and-error
with different formulations may be necessary to identify the ideal
supplement in order to maximize compliance.
There is a paucity of data on the utility of stool softeners and
laxatives in the treatment of symptomatic hemorrhoids. These
agents may be a useful adjunct for patients with severe chronic
constipation who do not experience optimal relief with bulking
agents alone.
Warm sitz baths and topical agents are frequently prescribed
components of a conservative treatment regimen. Dodi et al.
demonstrated a significant reduction in anal canal pressure after
patients with anorectal disorders soaked in water at 40ºC.(20)
Numerous topical agents are available for treatment of the acute
symptoms of hemorrhoids. Most of these agents provide a local
anesthetic effect which suppresses the burning and itching sensations associated with hemorrhoidal prolapse. While there is no
compelling data to support the use of these compounds, the risk
of side effects is relatively low and patients typically report some
symptomatic relief with their use. Patients should be advised to
limit the duration of use of topical steroids, as prolonged usage
has the potential to cause chronic perianal dermatitis.(21)
Sclerotherapy
Injection sclerotherapy, first described in 1869 by John Morgan
of Dublin, is the oldest form of nonsurgical hemorrhoid treatment still in use today. This technique was originally described
using iron persulphate to inject external hemorrhoids.(12) The
aim of sclerotherapy is to obliterate the vascular component of
the hemorrhoid and induce scarring to prevent further prolapse.
Sclerosants in current clinical use include 5% phenol in oil, 5%
quinine, and urea and 1–3% sodium tetradecyl sulfate. The sclerosant solution is injected by 25 gauge needle into the apex of each
hemorrhoidal bundle above the dentate line.(6–12) Sclerotherapy
is contraindicated in patients with inflammatory bowel disease,
portal hypertension, immunocompromised states, active anorectal infection, and prolapsed thrombosed hemorrhoids.(7)
Sclerotherapy is most effective for treatment of grade 1 or 2
internal hemorrhoids. Variable success rates have been reported
for this mode of therapy. In a 1988 survey, Mann et al. reported
that 88% of patients felt that their symptoms had improved at
4 weeks posttreatment.(22) In contrast, Senapati and Nicholls
demonstrated no significant difference in bleeding symptoms
in a randomized, controlled trial (n = 43). (23) Complications
associated with injection sclerotherapy are rare, and typically
result from deep placement of the injection. Urinary retention,
prostatitis, prostatic abscess, and mucosal sloughing have been
reported.(7–9)
Rubber Band Ligation
In medieval times, hemorrhoid ligation was performed by
encircling the entire prolapsed hemorrhoid with thread.(8)
This concept was modernized by Blaisdell in 1958 (24) and
was further refined by Barron in 1963 (25) with his description of hemorrhoid ligation using small rubber bands. Using
specialized instruments, rubber band ligation is performed by
grasping excess tissue at the hemorrhoid apex and deploying a
rubber band to constrict the hemorrhoidal blood supply. The
encircled tissue sloughs after 5–7 days, creating a scar that fixes
the remaining tissue to the rectal wall and consequently reduces
the degree of prolapse.
Rubber band ligation can be performed using a Barron or
McGivney hemorrhoid ligator coupled with a modified Allis
clamp, or with a McGown type suction ligator. (Figure 18.1) The
authors prefer the suction ligator, which is designed for singleoperator use. Rubber bands must be placed at least 2 cm above
the dentate line to avoid severe pain. If the patient expresses
discomfort during the tissue grasping/suction phase of the procedure, the procedure should be abandoned. Severe pain immediately following rubber ligation may necessitate band removal,
which can be performed using a hooked probe.(7) Alternatively,
injection of bupivacaine into the hemorrhoid above and below
the level of the rubber band provides several hours of relief and
subsequent pain is adequately treated with narcotics. While up
to three hemorrhoids can be banded in a single session (26, 27),
the authors typically limit treatment to one or two columns to
minimize patient discomfort related to excessive banded tissue
within the anal canal.
In a review of 39 published studies (8,060 patients), Wechter
found pain to be the most common complication (5.8%) following hemorrhoid banding. Other potential complications include
hemorrhage (1.7%), incontinence (0.9%), thrombosis (0.6%)
and infection (0.04%).(28) Patients may on occasion experience
vasovagal symptoms immediately after band placement, including diaphoresis, bradycardia, nausea, and hypotension.(12) This
usually spontaneously resolves after allowing the patient to lie
down for 10 to 15 minutes.
Postbanding hemorrhage typically occurs 4 to 7 days after the
procedure. It is related to the band falling off after necrosis of tissue is complete and is most commonly self-limited. More severe
bleeding may require operative ligation.
Although rare, several cases of postbanding sepsis have been
reported.(28–30) In a 2006 review, McCloud et al. examined
10 case reports of sepsis following rubber-band ligation of
(A)
(B)
improved outcomes in colon and rectal surgery
(C)
(c)
Figure 18.1 Banding an internal hemorrhoid. The internal hemorrhoid is teased into the barrel of the ligating gun with (A) a suction (McGown) ligator or (B) a
McGivney ligator. (C) The apex of the banded hemorrhoid is well above the dentate line to minimize pain.
hemorrhoids (17 total cases, 6 fatal). The majority of these 17
patients developed local or retroperitoneal abscesses within the
first week following banding. Common presenting symptoms
included perineal induration and pain, urinary difficulties, and
fever.(31) Patients with these or similar symptoms following
rubber band ligation of hemorrhoids should undergo a thorough clinical evaluation including appropriate imaging studies
(CT Scan) and physical examination, with initiation of broadspectrum antibiotics, and surgical drainage or debridement if
indicated.
Reported success rates for hemorrhoid banding vary according to
length of follow-up and grade of hemorrhoids treated. In 2004, Iyer
et al. reported a series of 701 patients who underwent rubber band
hemorrhoid ligation, with an overall success rate of 70.5%. The median
follow-up time was 1,205 days. Although there was not a statistically
significant difference in success between the 4 grades of hemorrhoids
treated, patients with grade 1 and 2 hemorrhoids demonstrated the
most improvement (72.4% and 73.1% respectively).(32) A 1998 survey of 92 patients by Savioz et al. found 77% and 68% of patients to be
free of symptoms at 5 and 10 years postbanding.(33)
nonoperative therapy for hemorrhoid disease
Figure 18.2 The infrared photocoagulator creates
a small thermal injury. Thus several applications
are required for each hemorrhoidal column.
Treatments 1st degree 2nd degree 3rd degree 4th degree Acute prolapse with
Dietary X X X X X
Banding X X X
Sclerotherapy X X X
Infrared coagulation X X X
Excisional
hemorrhoidectomy
Stapled
hemorrhoidopexy
Multiple
thrombectomies and
multiple bandings
Figure 18-3 Management of Hemorrhoids by Classification.
Infrared Photocoagulation
Infrared photocoagulation (IRC) utilizes infrared radiation to
induce protein necrosis at the base of the hemorrhoidal pedicle.
The depth of tissue penetration can be controlled by altering the
optical wavelength of the coagulator and the contact time.(9)
X X X Emergent
X X X (?)
X
Complications associated with IRC are infrequent. As with
rubber band ligation, pain can occur if the light is applied distal
to the dentate line but is typically of shorter duration and lesser
severity. Excessive applications can result in bleeding. Rarely,
ulceration can progress to fissure formation.(12)
Using a slotted anoscope to visualize the hemorrhoid, the procedure is performed by placing the tip of the photocoagulator at
the base of the hemorrhoid and delivering a 1–1.5 second pulse
of energy (Figure 18.2). Three or four applications to each hemorrhoid are recommended for optimal results. This creates a 3–4
mm2 area of coagulation which ulcerates and forms a scar within
2 weeks.(12) Most authors advocate treatment of 1–3 hemorrhoids per session. Additional treatments can be performed as
indicated at 3–4 week intervals.(7, 12)
COMPARISON OF TECHNIQUES
Numerous randomized trials have been published comparing the
available nonsurgical techniques for treatment of symptomatic
hemorrhoids. In a 1995 meta-analysis, MacRae et al. evaluated the
results of 18 of these studies. They found that patients treated with
rubber band ligation were less likely to require further therapy than
those treated with sclerotherapy (p = 0.031) or IRC (p = 0.0014).
However, the incidence of postprocedure pain was significantly
improved outcomes in colon and rectal surgery
higher in patients who underwent rubber band ligation than the
sclerotherapy (p = 0.03) and IRC (p < 0.0001) cohorts.(34)
SUMMARY
Most patients with symptomatic hemorrhoids can be successfully
treated with conservative management and nonsurgical techniques
performed in the office setting. The authors and editors generally
favor a conservative approach, beginning with a trial of supplemental
fiber with sitz baths and topical preparations for symptomatic relief.
If no improvement in symptoms results after 4–6 weeks, we proceed with rubber band ligation or IRC, repeating these techniques
if necessary at 4–6 week intervals. Symptomatic prolapse may be
an indication for rubber band ligation at the initial evaluation since
conservative treatment alone is unlikely to result in complete resolution. Surgical hemorrhoidectomy (discussed in chapter 17) may be
necessary in cases of failure of nonsurgical management, large grade
3 or 4 hemorrhoids or acutely thrombosed hemorrhoids. In all cases,
a careful history and physical examination is necessary to rule out
other causes of anorectal pathology. Management options for various classes of hemorrhoids are summarized in Figure 18.3.
REFERENCES
1. Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study.
Gastroenterology 1990; 98: 380–6.
2. Johanson JF, Sonnenberg A. Temporal changes in the occurrence of hemorrhoids in the United States and England. Dis
Colon Rectum 1991; 34: 585–93.
3. Thompson WHF. The nature of hemorrhoids. Br J Surg 1975;
62: 542–52.
4. Nivatvongs S. Hemorrhoids. In Gordon PH, Nivatvongs S,
eds. Principles and Practice of Surgery for the Colon, Rectum,
and Anus. 3rd ed. New York: Informa Healthcare USA, Inc,
2007: 143–66.
5. Margolin DA, Hammond KL. Hemorrhoids, Anal Fissure,
Perianal Abscess, and Fistula in Ano. In Rakel RE, Bope ET,
eds. Conn’s Current Therapy 2007. Philadelphia: Saunders/
Elsevier. 2007: 614–8.
6. Madoff RD, Fleshman JW. American Gastroenterological
association technical review on the diagnosis and treatment
of hemorrhoids. Gastroenterology 2004; 126: 1463–73.
7. Beck DE. Hemorrhoidal Disease. In Beck DE, Wexner SD, eds.
Fundamentals of Anorectal Surgery (2nd ed). W. B. Saunders
Company Ltd. 1998: 237–53.
8. Dennison AR, Whiston RJ, Rooney S, Morris DL. The management of hemorrhoids. Am J Gastroenterol 1989; 84(5): 475–81.
9. Hardy A, Chan CLH, Cohen CRG. The surgical management
of haemorrhoids: a review. Dig Surg 2005; 22: 26–33.
10. Cataldo P, NealEllis C, Gregorcyk S et al. Practice parameters
for the management of hemorrhoids (revised). Dis Colon
Rectum 2005; 48: 189–94.
11. Salvati EP. Nonoperative management of hemorrhoids:
evolution of the office management of hemorrhoids. Dis
Colon Rectum 1999; 42(8): 989–93.
12. Larach S, Cataldo TE, Beck DE. Nonoperative treatment of
hemorrhoidal disease. In: Hicks TC, Beck DE, Opelka FG,
Timmcke AE. Complications of Colon and Rectal Surgery.
Baltimore: Williams & Wilkins 1997: 173–80.
13. Alonso-Coello P, Mills E, Heels-Ansdell D et al. Fiber for the
treatment of hemorrhoids complications: a systematic review
and meta-analysis. Am J Gastroenterol 2006; 101: 181–8.
14. Moesgaard F, Nielsen ML, Hansen JB, Knudsen JT. Highfiber diet reduces bleeding and pain in patients with haemorrhoids: a double-blind trial of Vi-Siblin. Dis Colon Rectum
1982; 25: 454–6.
15. Webster DJ, Gough DC, Craven JL. The use of bulk evacuant
in patients with haemorrhoids. Br J Surg 1978; 65: 291–2.
16. Hunt PS, Korman MG. Fybogel in haemorrhoid treatment.
Med J Aust 1981; 2: 256–8.
17. Broader JH, Gunn IF, Alexander-Williams J. Evaluation of a
bulk-forming evacuant in the management of haemorrhoids.
Br J Surg 1974; 61: 142–4.
18. Tan KY, Seow-Choen F. Fiber and colorectal diseases: separating
fact from fiction. World J Gastroenterol 2007; 13(31): 4161–7.
19. Bennett WG, Cerda JJ. Benefits of dietary fiber: Myth or
medicine?. Postgraduate Medicine 1996; 99(2): 153–6, 166–
8, 171–2 passim.
20. Dodi G, Bogoni F, Infantino A et al. Hot or cold in anal pain?
A study of the changes in internal sphincter pressure profiles.
Dis Colon Rectum 1986; 29: 248–51.
21. Johanson JF. Nonsurgical treatment of hemorrhoids. J Gastrointest Surg 2002; 6(3): 290–4.
22. Mann CV, Motson R, Clifton M. The immediate response to
injection therapy for first-degree hemorrhoids. J R Soc Med
1988; 81: 146–8.
23. Senapati A, Nicholls RJ. A randomised trial to compare the
results of injection sclerotherapy with a bulk laxative alone in
the treatment of bleeding haemorrhoids. Int J Colorectal Dis
1988; 3: 124–6.
24. Blaisdell PC. Prevention of massive hemorrhage secondary to
hemorrhoidectomy. Surg Gynecol Obstet 1958; 106: 485–8.
25. Barron J. Office ligation treatment of hemorrhoids. Dis
Colon Rectum 1963; 6: 109–13.
26. Lee HH, Spencer RJ, Beart RW Jr. Multiple hemorrhoidal bandings in a single session. Dis Colon Rectum 1994; 37: 37–41.
27. Lau WY, Chow HP, Poon GP, Wong SH. Rubber band ligation of three primary hemorrhoids in a single session: a safe
and effective procedure. Dis Colon Rectum 1982; 25: 336–9.
28. Wechter D, Luna G. An unusual complication of rubber band
ligation of hemorrhoids. Dis Colon Rectum 1987; 30: 137–40.
29. O’Hara VS. Fatal clostridial infection following hemorrhoidal banding. Dis Colon Rectum 1985; 28: 291–3.
30. Russel TR, Donohue JH. Hemorrhoidal banding: a warning.
Dis Colon Rectum 1985; 28: 291–3.
31. McCloud JM, Jameson JS, Scott AND. Life-threatening sepsis
following treatment for haemorrhoids: a systematic review.
Colerectal Disease 2006; 8: 748–55.
32. Iyer VS, Shrier I, Gordon PH. Long-term outcome of rubber
band ligation for symptomatic primary and recurrent internal hemorrhoids. Dis Colon Rectum 2004; 47: 1364–70.
33. Savioz D, Roche B, Glauser T et al. Rubber band ligation of
hemorrhoids: relapse as a function of time. Int J Colorect Dis
1998; 13: 154–6.
34. MacRae HM, McLeod RS. Comparison of hemorrhoidal
treatment modalities: a meta-analysis. Dis Colon Rectum
1995; 38: 687–94.
9
Surgery and nonoperative therapy of perirectal abscesses and anal fistulas
Brian R Kann and Charles B Whitlow
CHALLENGING CASE
A 40-year-old male with poorly controlled HIV infection develops
severe anorectal pain with associated fever. On physical examination, an obvious perirectal abscess is present 2 cm from the anal
verge, just to the right of the posterior midline. Appropriate incision and drainage is performed and the patient is treated with a
short course of oral antibiotics, with resolution of the acute event.
Several months later, he presents with purulent discharge from
the drainage site as well as a second area in the posterior midline,
4 cm from the anal verge. Exam under anesthesia demonstrates
a single primary fistula opening anal canal, in the posterior midline 3 cm proximal to the dentate line, which communicate with
both secondary openings. Draining setons are placed, and biopsies from the fistula tracts show no evidence of Crohn’s disease
or malignancy. Six weeks later, he presents in septic shock due to
worsening perineal infection requiring a diverting colostomy.
CASE MANAGEMENT
The patient is initially managed with additional drainage and a
diverting colostomy. After recovering, he is initiated on highly
active anti-retroviral therapy (HAART) with an excellent response
in his CD4 count and his viral load become undetectable. After an
MRI of the pelvis demonstrates no further infection in the pelvis,
an anal fistula plug is placed to attempt to close the fistula; within
a week, the plug has dislodged. An attempt at closing the fistula
with an endorectal advancement flap several weeks later also fails.
Further biopsies again show no evidence of Crohn’s disease or
malignancy, and a second attempt at endorectal advancement
flap closure performed 12 weeks later also fails. The patient has
decided not to pursue further surgery for the fistula and remains
diverted via a colostomy with draining setons in place.
abscesses and fistula-in ano. Abscesses are classified according to their location in relation to the potential anorectal
spaces (perianal, ischiorectal, intersphincteric, and supralevator) (Figure 19.1). Pus can spread circumferentially through
the intersphincteric, supralevator, and ischiorectal spaces.
Circumferential spread though contralateral ischiorectal spaces
can occur via the deep postanal space, resulting in formation
of a horseshoe abscess. Anal fistulas are classified according to
their relationship to the anal sphincter complex (intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric),
as described by Parks (Figure 19.2).(2)
The diagnosis of most anorectal abscesses is typically straightforward. Patients usually complain of pain and swelling at the
site, and fever is not uncommon. Examination will demonstrate
(A)
INTRODUCTION
Anorectal abscesses and fistulae-in-ano can be incredibly frustrating,
both for the patient and the managing physician. Meaningful outcomes
data with large, prospective randomized trials regarding the management of these entities is extremely limited. This chapter addresses the
surgical as well as nonoperative management of these common problems, focusing on means of improving clinical outcomes.
ETIOLOGY AND DIAGNOSIS
The vast majority of anorectal abscess are cryptoglandular, resulting
from obstruction of the anal ducts and glands, resulting in stasis,
infection, and abscess formation.(1) Less common causes include
inflammatory bowel disease, tuberculous infection, trauma, malignancy, and radiation. Most anal fistulas are the long-term manifestations of anorectal abscesses; persistent epithelium in the tract
between the infected duct and external opening created by surgical
or spontaneous drainage leads to fistula formation.
An intricate understanding of anorectal anatomy is essen-
tial to the diagnosis and subsequent management of anorectal
(B)
Figure 19.1 Anorectal spaces. (A) Coronal section. (B) Sagital section.
improved outcomes in colon and rectal surgery
(A) (C)(B) (D)
Figure 19.2 Classification of fistula-in-ano. (A) Inttersphincteric. (B) Trans-sphincteric. (C) Suprasphincteric. (D) Extrasphincteric.
elicited on rectal examination. Identification of the internal
(primary) opening by anoscopy is usually difficult, and exam
under anesthesia is often required. Goodsall’s rule Figure 19.3 is
useful, though its reliability has been questioned, especially when
dealing with anterior fistulas; Cirocco and Reilly demonstrated
that in patients with anterior secondary fistula openings, 71%
tracked to an anterior midline primary opening, and in women
with anterior secondary fistula openings, only 31% tracked radially inward to the nearest crypt.(3)
Because of the difficulties in defining fistula anatomy, preoperative imaging has, in many cases, become common practice. Available
imaging modalities include CT scan, fistulography, endoanal ultrasonography, and magnetic resonance imaging (MRI). CT scanning
is really useful only in defining abscesses related to fistulas.(4) CT
attenuation of the anal sphincter and pelvic floor is similar to that
of the fistula itself; therefore, the fistula itself is difficult to see
unless it is filled with air or contrast.(5) Fistulography as an initial diagnostic measure has several limitations.(6) Smaller extensions from the primary tract may not fill with contrast if they are
plugged with debris. Also, there is no visualization of the sphincter complex or levator ani in relation to the location of the fistula.
Besides creating the potential for spread of sepsis, accuracy rates
Figure 19.3 Goodsall’s rule.
erythema, swelling, and possibly fluctuance at the site of the
abscess. Severe rectal pain associated with defecation and a
paucity of physical findings should raise one’s suspicion for an
intersphincteric abscess. Confirmation generally requires exam
under anesthesia with palpation of a fluctuance within the wall
of the anal canal or needle aspiration of purulent material from
the intersphincteric space. Severe gluteal pain in the absence of
significant findings on exam may be suggestive of a supralevator
abscess. Supralevator abscesses may develop as an upward extension of an ischiorectal or intersphincteric abscess, or they may
develop as a downward extension of a pelvic abscess. Exam under
anesthesia and/or computed tomography (CT) imaging is generally required for diagnosis.
The initial diagnosis of fistula-in-ano is also fairly straightforward, though classifying the type of fistula and defining the
anatomy can be much more difficult. The patient will usually
give an antecedent history of an abscess that has either drained
spontaneously or required surgical drainage. Examination may
demonstrate an external (secondary) opening seen as an elevation of granulation tissue with a discharge of pus, sometimes
are poor, ranging from 16–48%, with a false positive rate of 12%.
(6, 7) The place of fistulography may be in evaluating recurrent
fistulas, patients with Crohn’s disease, and patients who have had
multiple prior anorectal procedures with altered anatomy (7),
though with more readily available endoanal ultrasound and anal
MRI, its use will likely continue to decline.
The use of anorectal endosonography in the diagnosis of anorectal fistulas has gained considerable attention in recent years.
It helps to identify the anatomy of the fistula in relation to the
sphincter and may also be used to aid in delineation of complex
fistulae and occult suppuration.(8, 9) The technique is relatively
simple, inexpensive, readily performed in an office setting, and
well tolerated by the patient. Lengyel et al. reported that endorectal ultrasound correctly predicted surgical findings in 124 of 151
(82%) patients with anal fistulas.(10)
Some concerns have arisen regarding the sensitivity of endoanal
ultrasound. Seow-Choen prospectively demonstrated poor sensitivity in detecting primary extrasphincteric and suprasphincteric tracts and secondary supralevator or infralevator tracts.(11)
The use of hydrogen peroxide injected into the fistula tract can
improve the sensitivity of endorectal ultrasound for evaluation
of anorectal fistulas. Cheong demonstrated a 24% increase in
locating fistula tracts and a 28% increase in the demonstration
surgery and nonoperative therapy of perirectal abscesses and anal fistulas
of primary fistula openings with the addition of hydrogen peroxide.(12) Other studies have confirmed the increased sensitivity of
hydrogen peroxide-enhanced endorectal ultrasound, with some
studies reporting concordance rates as high as 95%.(13–16)
The use of three-dimensional endoluminal ultrasound (3D-EUS)
has greatly increased the sensitivity of identifying and defining fistula anatomy.(17) A study by Giordano et al. comparing 3D-EUS
to conventional (two-dimensional) EUS found that 3D-EUS was
significantly more accurate in assessing the fistula tract and site of
primary opening.(18) As with conventional EUS, the sensitivity of
3D-EUS is increased even further with the injection of hydrogen
peroxide into the fistula tract.(19) In a comparison with endoanal
MRI, hydrogen peroxide-enhanced 3D-EUS was found to be superior for detection of secondary fistula tracts, fluid collections, and
determining the location of primary fistula openings.(20, 21) The
authors suggested hydrogen peroxide enhanced 3D-EUS as a less
expensive, yet equally sensitive, alternative to endoanal MRI.
Anorectal MRI has emerged as a valuable tool in assessing
complex anorectal fistulas. The best spatial resolution is achieved
by using a dedicated endoanal coil, combined with a surface
coil to increase the field of view.(5) The precise location of the
primary opening can be identified and information regarding the
relation of the fistula to the sphincter, sphincter integrity, secondary tracts, and supralevator extension can be obtained. However,
the disadvantages include expense and expert interpretation
which may not be readily available in all centers.
In a study of 104 patients comparing clinical examination, endoanal ultrasonography, and MRI, accurate classification of fistula
anatomy by MRI was 97%, compared with 81% by ultrasound,
and 61% by clinical examination.(22) Barker reported concordance
rates for MRI diagnosis of 86% for primary fistula tracts, 91% for
secondary extensions, 97% for the presence of horseshoe abscess,
and 80% for the position of the primary opening.(23) In this study,
failure of healing in 9% of patients was due to pathology missed at
the time of surgery that was seen on preoperative MRI. Beckingham
demonstrated a sensitivity and specificity of MRI for detecting anorectal fistulas of 100% and 97%, respectively.(24) In this study, MRI
missed only one fistula with a complex transsphincteric tract.
Phased array (PA) MRI can provide even more precise information regarding fistula anatomy when compared with body coil
MRI. Beets-Tan et al. (25) reported a study in which PA-MRI was
performed in 56 patients who then underwent fistula surgery. The
surgeons were initially blinded to the MRI findings until they felt
that they had determined the course of the fistula intraoperatively,
at which point the PA-MRI findings were revealed. In 12 (21%)
patients, PA-MRI imaging added additional information regarding
fistula tract anatomy not found by the surgeon on initial exploration. The highest benefit was in patients with Crohn’s disease
(40%) and recurrent fistula-in-ano (24%).
An emerging technique in the imaging of anal fistulas is highresolution MR fistulography, in which images are obtained before
and after the intravenous injection of gadolinium, following
which images are subtracted that show only enhancing tissues,
i.e., the wall of the fistula tract.(5) Schaefer et al. (26) performed
a study of 36 patients who underwent preoperative MR fistulography, then underwent fistula surgery with the surgeon blinded
to the MRI results. When operative findings were compared with
MRI findings, 89% agreement was seen. In all four patients in
which there was discordance between operative findings and MR
findings, multiple complex fistulas and abscesses in a setting of
Crohn’s disease were present.
In terms of improving the outcomes of patients who will require
surgery for anal fistulas, it is well established that clear identification of the anatomy is essential. Regardless of the modality used, it
seems prudent, with the technology available today, that preoperative imaging of anything more than a simple intersphincteric or
low transsphincteric fistula be performed to minimize the potentially significant morbidity associated with anal fistula surgery.
SURGICAL MANAGEMENT
Incision and Drainage
The mainstay of treatment of anorectal abscesses is incision and
drainage. There is no role for treatment with antibiotics alone without drainage. Most perianal and superficial ischiorectal abscesses
can be drained in the office or emergency room setting after infiltration of local anesthetic. A cruciate incision should be made over
the area of fluctuance, taking care to stay as close to the anal verge
as practical in the event that a fistula develops later. The skin edges
should be excised to allow for adequate drainage without the need
for continued packing. Alternatively, catheter drainage may be
employed, as described by Beck (27), making a small incision over
the area of fluctuance and placing a small (10–16 French) mushroom-tipped catheter in the abscess cavity. The catheter is typically
removed when the drainage has decreased and the abscess cavity
has closed down around the drain (usually 5–10 days later). Care
should be taken not to cut the catheter too short to prevent it from
retracting completely into the abscess cavity.
Larger ischiorectal abscesses may require sedation, regional
anesthesia, or general anesthesia for sufficient drainage. Adequate
patient comfort is essential, as attempts to drain an abscess in an
inadequately anesthetized patient lead to unnecessary patient distress, and will almost assuredly result in incomplete exploration
and drainage of the abscess.
Intersphincteric abscesses should be drained via division of
the internal sphincter along the length of the abscess, followed by
marsupialization of the wound. Drainage of a supralevator abscess
depends on the etiology of the abscess. If it arises from an intersphincteric abscess, drainage should be performed transrectally by
division of the internal sphincter, as external drainage would result
in the development of a suprasphincteric fistula. If the origin is
an ischiorectal abscess, drainage should be performed externally,
through the perianal skin. If the abscess originates from an infectious process in the pelvis, drainage may be performed through
the rectum, ischiorectal fossa, or abdominal wall by percutaneous
drainage, ensuring that the primary infectious process is addressed.
Management of horseshoe abscesses and fistulas can be especially
problematic. Adequate treatment of horseshoe abscesses typically
requires drainage of the deep postanal space via a midline incision
between the coccyx and anus, spreading the fibers of the superficial
external sphincter. An open internal sphincterotomy is performed
in the posterior midline and counter-incisions are made over each
ischiorectal fossa to allow for drainage of the anterolateral extensions of the abscess, as initially described by Hanley.(28) Rosen et al.
improved outcomes in colon and rectal surgery
(29) reported that patients with horseshoe abscess/fistula required
a median of 4 (range 1–9) operations; at a mean follow-up of 49.3
months, 60.7% of patients had either healed perineal disease or were
asymptomatic with controlled disease. Those who underwent posterior midline sphincterotomy as part of their surgical management
were more likely to be asymptomatic postoperatively (p = 0.047).
There is little role for antibiotics after adequate surgical drainage of an anorectal abscess. Those for whom treatment with
antibiotics should be considered postdrainage include patients
with valvular heart disease or prosthetic valves, extensive soft
tissue cellulitis or induration, prosthetic devices, joint replacements, diabetes, and those who are immunocompromised or
immunosuppressed.(30)
Fistulotomy
The surgical management of anal fistulas rests on three main principles: eliminating the fistula, preventing recurrence, and preserving
sphincter function. Identification of the primary opening and division of as little sphincter muscle as possible are essential to achieving
these outcomes. Methods used intraoperatively to identify the primary opening include passage of a probe, injection of a dilute solution (hydrogen peroxide, methylene blue, or milk) via the secondary
opening, tracing granulation tissue present in the fistula tract, and
identifying puckering of the anal crypt when traction is placed on
the tract.(30) Preoperative determination of fistula anatomy may
also be determined using imaging modalities, as described earlier.
Most simple intersphincteric fistulas and low transsphincteric
fistulas can be managed by simple “lay-open” fistulotomy with
curetting of the tract and marsupialization of the wound edges.
Higher transsphincteric, extrasphincteric, and suprasphincteric
fistulas are generally not appropriate for simple fistulotomy, as the
end result would be division of a large portion of anal sphincter,
resulting in altered fecal continence.
Primary fistulotomy at the time of initial abscess drainage is controversial. Some argue that in the acute phase it is easier to trace
the supporative process and identify the fistula tract. This eliminates
the source of infection and may decrease the rate of recurrence; in
turn, this may potentially eliminate the need for further surgery and
its accompanying morbidity. Fucini reported no recurrences in 51
of 58 primary fistulotomies where an internal opening could be
identified and no “major” incontinence, though impaired control
of flatus was seen in 17%.(31) Tang et al. showed in a prospective
randomized trial of drainage alone versus drainage and fistulotomy
for acute perianal abscesses that there was no statistical significance
in terms of recurrence.(32) The concept of primary fistulectomy
at the time of abscess drainage also is controversial. Schouten and
van Vroonhoven prospectively demonstrated that fistulectomy was
associated with clinically significant disturbances in anal function in
39.4% of patients treated with primary fistulectomy, compared with
21.4% of patients treated with secondary fistulectomy.(33)
Seton Placement
In the management of higher transsphincteric fistulas, preserving
the sphincter becomes even more essential. In these instances, placement of a seton may be of benefit. A seton may be used in a cutting
fashion by dividing the skin and lower portion of the anal sphincter
and gradually tightening the seton over regular intervals. A seton
may also be used to allow for prolonged drainage, without gradual
tightening. Indications for the use of a seton include identification
and promotion of fibrosis around a complex fistula that encircles
most of the sphincter, marking the site of a transsphincteric fistula in cases of severe anorectal sepsis where the normal anatomic
landmarks have been distorted, in anterior high transsphincteric
fistulas in women, in high transsphincteric fistulas in HIV-positive
patients with poor wound healing, to promote long-term drainage
in patients with Crohn’s disease, and when there is suspicion that a
primary fistulotomy will result in incontinence.(34)
Treatment of suprasphincteric fistulas can become extremely
complex, as laying-open of the entire fistula tract would inevitably
lead to incontinence. The use of a cutting seton in combination
with division of the internal sphincter and the superficial portion
of the external sphincter to the level of the secondary opening
has been reported with successful healing in 63% of patients.
(35) Kennedy and Zegarra (36) described a modification of this
approach using internal sphincterotomy along with opening of
the tracts outside the external sphincter without division of any
portion of the external sphincter, which is encircled by a seton to
promote fibrosis and drainage; they reported complete healing in
66% of posterior fistulas and 88% of anterior fistulas.
Extrasphincteric Fistulas
Surgical management of an extrasphincteric fistula depends on its
etiology. If it arises as a consequence of an anal fistula, the lower
portion of the internal sphincter is divided and the rectal opening
is closed with a nonabsorbable suture, with or without temporary
diversion. If the fistula is the result of trauma, drainage must be
performed along with closure of the rectal opening and proximal
diversion. If the fistula is the result of downward tracking of a pelvic
abscess, treatment of the primary process is essential. It is prudent
to have a low threshold for temporary proximal diversion, as progressive perineal sepsis can lead to devastating consequences.
Advancement Flap
In patients for whom primary fistulotomy is not appropriate,
the use of an anorectal or endorectal advancement flap is a useful alternative. These patients include women with anterior fistulas, patients with inflammatory bowel disease, patients with
high transsphincteric and suprasphincteric fistulas, and those
with multiple previous fistula operations.(37, 38) A full-thickness
flap incorporating a portion of the internal sphincter should be
advanced at least a centimeter beyond the primary fistula opening
and sutured into place with absorbable sutures without tension
(Figure 19.4).
Schouten et al. (39) reported successful fistula closure in 33
of 44 (75%) patients with anal fistulas treated with endorectal
advancement flaps. In patients with no or only one attempt at
repair, the healing rate was 87%, compared with 50% in those
with two or more prior attempts. In a series of 107 patients with
anal fistulas arising from a number of etiologies who underwent
endorectal advancement flap, Kodner et al. reported successful
healing in 93% of patients, though nine patients initially failed
and required a second procedure.(40) In a series of 29 patients
with cryptoglandular and obstetric-related fistulas, Dixon et al.
(41) reported 69% (20 of 29) fistula resolution with endorectal
surgery and nonoperative therapy of perirectal abscesses and anal fistulas
(A)
Figure 19.4 Anorectal advancement flap. (A) Transphincteric fistula in ano. (B) Enlargement of external opening. (C) Flap of mucosa and muscle created. (D) Flap
advanced and closed after excision of distal edge containing fistula.
(B)
advancement flaps at 3 months follow-up. Additionally, of the
nine patients who failed, fistula resolution was seen in 4 (44%)
after a second procedure, for a total success rate of 83%. Healing
rates of 63.3% to 81% have also been reported for the use of
endorectal advancement flaps for the management of complex
anal fistulas.(42, 43)
Endoanal advancement flaps have also been utilized with varying degrees of success in the management of anal fistulas. Chew
and Adams (44) reported successful fistula closure using an anal
sphincter advancement flap, as opposed to an endorectal advancement flap, in six patients with a mean, follow-up of 8.1 months.
Amin et al. (45) reported overall 83% healing in patients undergoing V-Y advancement flaps for fistula closure, although two
patients required repeat surgery. Continence was preserved in all
patients. Zimmerman et al. (46) reported only 46% healing with
anocutaneous advancement flaps, with success inversely correlated
with the number of previous attempts at fistula repair.
(C)
(D)
a median follow-up of 22 months, including retreatment of initial failures. Even less favorable healing rates of 14–33% have been
reported in other series.(52–54)
More recently, improved outcomes in larger series have been
published. In prospective study of 36 patients, Maralcan et al.
reported a complete healing rate of 83.3% at a mean follow-up
of 54 weeks.(55) Adams et al. reported healing in 66% of patients
treated with fibrin glue with a mean follow-up of 3 months, with
94% of these patients asymptomatic at 6 month follow-up.(56)
Fibrin glue has also been evaluated as an adjunct to advancement flap closure of anal fistulas. Ellis and Clark (57) performed a
prospective, randomized, controlled study comparing flap repair
alone (n = 30) to flap repair with fistula tract obliteration using
fibrin glue (n = 28). At a median follow-up of 22 months, the
recurrence rate for fistulas treated with advancement flaps alone
was 20%, compared with 46.4% for fistulas treated with advancement flaps with fibrin glue (p < 0.05). The authors postulated
that obliteration of the fistula tract with fibrin glue may prevent
Fibrin Glue
The injection of fibrin glue into the tract(s) of a fistula-in-ano is
a simple method used to impart closure. Advantages include easy
application, preservation of sphincter integrity, minimal patient
discomfort, and the opportunity to repeat applications when the
initial treatment fails. Earlier trials utilized injection of autologous
fibrin adhesive prepared from the patient’s own blood. Cintron
et al. reported successful healing in 22 of 26 patients treated
with autologous fibrin at a mean follow-up of 3.5 months.(47)
The same group reported less success (17 of 25 patients) with a
commercially produced sealant.(48) Less favorable results were
seen at a mean follow-up of 1 year, with 54% healing in patients
treated with autologous fibrin sealant and 64% healing in patients
treated with commercially produced fibrin sealant.(49) Most failures occurred within the first 3 months, though failures were seen
as late as 11 months postoperatively.
Additional studies initially failed to show consistent results.
A small randomized, controlled trial comparing fibrin glue to conventional treatment (fistulotomy or seton placement with or without later advancement flap) failed to show an advantage to fibrin
glue for simple fistulas, though more complex fistulas healed with
fibrin glue (69% vs. 13%, p = 0.003).(50) Sentovich (51) reported
complete healing in 17 of 20 (85%) patients treated with fibrin glue
at a mean follow-up of 10 months, though he later reported a less
favorable healing rate of 69% in a larger series of 48 patients at
effective drainage from beneath the advancement flap, leading
to a higher failure rate. Van Koperen et al. (58) also showed that
outcomes were worse when obliteration of the fistula tract with
fibrin glue was combined with endorectal advancement flap.
As a more economical alternative to fibrin glue, Jain et al. (59)
proposed using cyanoacrylate glue as a means toward achieving fistula closure. They reported complete fistula closure at 6 month follow-up in 17 of 20 patients after primary injection, and complete
healing in two of the three initial failures after a second injection,
for a composite 95% healing rate. Proposed advantages of cyanoacrylate as opposed to fibrin include a cost reduction of approximately two-thirds, commercial preparation in premade collapsible
tubes that do not require premixing, and a longer shelf-life. Barilleri
et al. (60) reported similar results with complete healing at 18 month
follow-up in 15 of 21 patients. Four additional patients healed with
repeat applications, for a composite healing rate of 90.2%.
Modifications of the fibrin adhesive technique have been
attempted, also with little improvement. The addition of cefoxitin
to the fibrin adhesive failed to improve healing rates in a study
performed by Singer et al. nor did closure of the primary opening.
(61) In fact, healing rates with both modifications were lower than
their earlier published result with fibrin adhesive alone.(47, 48)
Gustafsson and Graf (62) looked at the addition of a gentamycinenriched collagen adhesive beneath rectal advancement flaps and
found no difference in healing rates. In a prospective study with
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