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Front
a
External opening
4 Clinical Manifestations ofAnal Fistula
4.2 Signs
The typical anal stula consists of three parts: the
external orice, the stula tract, and the internal
orice (Fig.4.1). Usually, the external opening is
connected with the hard rope-like canal, which
goes straight or obliquely to the anus. There are
often scleroma and tenderness in the internal
dental line of the anus. Sometimes the external
opening closes and sometimes bursts. In the inactive period, the external orice of anal stula is
closed and there is no evident purulence
(Fig.4.2). When the external orice bursts, purulent secretions may ow out from the external
orice. In the acute attack period, there may
appear light or heavy perianal swelling and protuberance (Figs.4.3, 4.4, and 4.5). See Chap. 5
for details.
45
Fig. 4.2 Multiple anal stula rest period
Fig. 4.1 The basic shape of anal stula
Dentate Line
Anal cryp
Internal opening
Primary fistula
Primary abscess
Secondary fistul
Fig. 4.3 Anal stula mildly active period
Fig. 4.4 Anal stula moderate active period
46
Fig. 4.5 Anal stula severe period
R. Shi and H. Mao
Suggested Reading
1. Naijian Huang. Chinese Anorectal Diseases. Jinan:
Shandong Science and Technology Press, 1996.
2. Yin Yu, Traditional Chinese Medicine Diagnosis of
Anal Fistula. World Health Digest, 2011, 08 (8):
405–406.
Common Methods ofExamination
forAnal Fistula
RenjieShi andLihuaLiu
5
Abstract
The lateral position is widely applied for anal
stula examination. The rst step is observing
the external opening around the anus and
checking its amount, location, shape, distance
from the anus, the characteristics of secretion
in the external opening, the color of the skin
around the anus, and the absence of defects in
the anal canal. In the palpation, the exterior of
anus is touched rstly, and then the interior of
anus, and, if necessary, a combination of internal and external palpation should be done. The
keypoints of palpation are the direction of stula, the location of internal opening, and the
integrity and elasticity of the anal and rectal
ring. Probe exploration helps to understand the
direction of stula and the condition of the
internal opening and should be conducted gently. The staining examination of stula is helpful to conrm the location of internal opening
and penetration of anal stula. Ultrasonic
examination and MRI examination are the
most important test methods of anal stula
examination, as they are effective in determining the direction and location of anal stula, in
R. Shi (*)
Department of Anorectal Surgery, Afliated Hospital
of Nanjing University of Traditional Chinese
Medicine, Nanjing, Jiangsu, China
L. Liu
Nanjing Jiangbei Hospital, Nanjing, Jiangsu, China
exploring the relationship between stula and
sphincter, and in nding the internal opening
of anal stula. In addition, in the diagnosis of
anal stula, bacterial culture, histopathology,
stula angiography, colonoscopy, and other
means are necessary sometimes. The common
methods of anal function examination and
evaluation before and after anal stula surgery
are anorectal pressure measurement, ultrasonic
examination, MRI, pelvic oor electromyography examination, anorectal sensory function
examination, anal function scale evaluation,
and a questionnaire survey of patient life’s
quality.
Keywords
Anal stula · Inspection · Body position
Visual examination · Palpation · Exploration
Ultrasonic · Magnetic resonance imaging
CT · Colonoscopy
In order to make a denite diagnosis of anal stula, and to know the type, location, number,
course, relationship with anal sphincter, the possible nature of anal stula, and the presence or
absence of concurrent lesions of anal stula, it is
necessary to make some examinations. The
examination of anal stula can be divided into
two categories: systemic examination and local
© Chemical Industry Press 2021
R. Shi, L. Zheng (eds.), Diagnosis and Treatment of Anal Fistula,
https://doi.org/10.1007/978-981-16-5804-4_5
47
48
R. Shi and L. Liu
examination. This chapter mainly discusses the
local examination methods for anal stula,
including general specialist examination without
special equipment and auxiliary examination
with special equipment.
Prior to examining a patient, the patient’s
medical history needs detailed inquiry, and a preliminary diagnosis should be considered based
on the patient’s age, gender, and chief complaint,
followed by a focused and targeted examination.
If the patient complains that the anus is often
swollen and painful or moist and discharges pus
with months or even years of intermittent attacks,
the initial diagnosis should be considered as anal
stula. Afterward, specialized examination combined with visual examination, digital rectal
examination, probe inspection and anoscopy,
endoanal ultrasound, and MRI of rectoanal canal
can be performed as needed.
The purpose and signicance of examination
should be briey explained to the patient before
the specialist examination. For patients who are
nervous and afraid of the examination, appropriate comfort should be offered, and their understanding and cooperation should be obtained.
The medical history of patients with anal stula should include the following contents: previous treatment history of the patient, history of
drug allergies, history of women’s pregnancy and
menstruation, and whether there are any other
medical histories of hypertension, cirrhosis, heart
disease, blood disease, hepatitis, nephritis, etc.
Colonoscopy should not be performed in the following patients: women during pregnancy and
menstruation, patients with mental illness, and
those with severe heart or brain diseases. For
these patients, even undergoing anoscopy should
be done with caution. Radiological examination
is prohibited for pregnant women. Patients who
have been taking anticoagulants must stop using
anticoagulants for one week before they can
undergo colonoscopy and other examinations.
Before examination, necessary preparations
should be made. For example, before anal digital
examination and rectal examination, patients
need to empty their bowels and urinate, and
before colonoscopy and barium enema examination, the bowel should be cleaned.
Also, be careful to palpate gently. Care should
be taken to protect patient privacy. When male
doctors examine female patients, female doctors,
nurses, or family members should be present in
principle. For children or those who cannot take
care of themselves in life, family members should
accompany and assist them.
5.1 Special Examinations ofAnal
Fistula
5.1.1 Common Positions
Clinically, an appropriate body position can be
chosen according to the examination method and
the patient’s physical condition when undergoing
physical examination of anal stula. The usual
positions are the following three.
5.1.1.1 Lateral Position
The patient lies on his side, bends his hip, and
exposes his hip. This is a common examination
and treatment position. The advantage is that it is
simple and convenient; even for the disabled and
inrm, this is an easy position to take. This position is suitable for outpatient examination and
minor surgery. The disadvantage is that the anus
of obese patients is not fully exposed, so it is
often needed for the patient to use his hand to pull
the nonimplantation side of the hip to help expose
the anus.
5.1.1.2 Knee-Chest Position
The patient lies prone with chest close to the bed
and kneels down on the bed. The advantage is the
abdominal wall of the patient naturally sags and
does not compress the bowel cavity. This position
is suitable for observing the intestine during a
sigmoid colonoscopy. It is a common position for
rectal cancer and sigmoidoscopy. The disadvantage is that this position is not easy to do and
patients can become tired very quickly, especially
for the elderly, inrm, or overweight.
5.1.1.3 Lithotomy Position
Also called the bladder lithotomy position. The
patient lies on his back, moves his hips to the
5 Common Methods ofExamination forAnal Fistula
edge of the operating table, and places his two
legs on the two leg racks on both sides. During
operation, the lower limbs placed on the leg racks
need to be properly xed. The advantage of this
position is that the anus is exposed and the eld
of vision is good, convenient for examination and
surgery, and so it is the commonly used position
of anorectal examination and surgery. Its disadvantages are long preparation time, complete
exposure of genitals, and easy for the operator to
become tired and is difcult position for the
assistant. When maintaining this position for a
long time, it is easy to oppress the veins and
nerves of the patient’s lower extremities and
occasionally causes certain complications.
5.1.2 Inspection Methods
5.1.2.1 Visual Examination
Visual examination is to use the eyes to observe
the changes in the following contents: the shape
of the anus, the scope of lesions, the position of
the external opening of the anal stula, the number, the shape, and the characteristics of the
secretion.
49
Fig. 5.1 Appearance of anal stula recurrence
Appearance ofAnus
Anal stula can often lead to perianal local or
irregular swelling. The perianal tissue defects,
depressions, and bumps are often seen in patients
with anal stula surgery (Fig.5.1). Some patients
have anal relaxation after anal stula, and even a
little traction can be seen in the rectal mucosa,
suggesting the presence of anal incontinence.
These patients are often accompanied by anal
moisture, overow, perianal skin redness, or even
erosion. The perianal skin of Crohn’s disease
patients is typically moist and shiny (Fig.5.2).
External Openings ofAnal Fistula
1. The Number of External Openings of Anal
Fistula
There can be one or more or even dozens
of external openings of the anal stula.
However, there are also some patients who do
not have any obvious external opening, and
Fig. 5.2 Perianal of patients with Crohn’s disease and
anal stula
these are termed the external blind stula.
Simple anal stula has only one external
opening, and those with more than two external openings are mostly complex or multiple
anal stulas. When there is more than one that
breaks either sides or rear of the anus, it is
often a horseshoe stula. Most of the stulas
with an anterior external opening are not connected with each other, and most of them
belong to different stula groups. When the
anal stula with an anterior external opening
is far from the anus, it is often possible to
invade the scrotum subcutaneously. If many
external openings locate on one or both sides
of anus, most of the pipelines are complex,
and the diagnosis is complex anal stula. In
patients with extensive lesions of complex
50
R. Shi and L. Liu
Fig. 5.3 Appearance of complex anal stula Fig. 5.4 The external opening of anal stula may bulge
due to repeated inammation
anal stula, the skin surface can be uneven,
and the number and shape of external openings are different (Fig.5.3).
2. The Distance Between the External
Opening and the Anus
Generally, if the external opening is close
to the anus, the tract is straight. If it is distant
from the anus, the pipeline is curved and is
more complex. There are some exceptions;
although in some patients the external opening is close to the anus, the pipeline is however curved, and the position is deeper. Some
external openings are so far apart from the
anus, the pipeline is actually quite straight,
Fig. 5.5 Appearance of anal stula active period
and the surface is shallow.
3. Appearance of the External Opening
For the elderly with a long history of anal
tions such as pus and blood often ow out of
the opening.
stula, due to the repeated purulent swelling,
hyperplasia of the tissue, and uplift, the external openings are often nodular, and there are
also scar depressions. There is a stula in the
central area of the tubercle or depression
(Fig.5.4). The external opening with nodular
uplift is mostly anal stula caused by general
inammation. If the outer edge of anal stula
is curled inward, the granulation tissue is gray
and bright, and most of them are diagnosed as
tuberculosis anal stula.
When the anal stula is in the static stage,
the external opening is often closed. In the
attack stage, the external opening of the anal
stula is often broken (Fig. 5.5), and secre-
Secretions
If the pus from the external opening of anal stula is gray or golden, the thick texture is mostly
caused by common bacteria. If the pus is mixed
with blood or light red, it usually breaks up soon
or is in the acute inammation stage. If the pus is
gray-white or yellow-white and accompanied by
a heavy odor, it is mostly caused by E. coli or
Staphylococcus aureus infection. If the pus is
green, there is likely to be a Pseudomonas aeru-
ginosa infection. When the pus has uniform yellow particles, this suggests actinomycetes
infection. When the pus is either thin or like the
water that cleans out rice, it may be caused by
5 Common Methods ofExamination forAnal Fistula
Fig. 5.6 Suppurative apocrine inammation complicated
by anal stula
51
Fig. 5.7 Solomon’s law
tuberculous anal stula or inammatory bowel
disease. The possibility of malignant tumors,
such as mucinous adenocarcinoma, should be
considered if there is transparent gelatinous or
coffee-colored bloody mucus in the exocrine
secretions.
Skin Color Changes intheAnal Fistula
Lesion Area
In common anal stula, the perianal skin often
has no obvious changes, but the color of perianal
skin can also be deepened in patients with
long- term nonhealing of ulceration (Figs.5.3 and
5.4). In tuberculous anal stula, there is often a
brown round halo around the external opening. If
the skin in the duct area presents a diffuse dark
brown, or there is normal skin color between the
changed skin colors, or there is an obvious or dull
brown halo, the subcutaneous cavity is often
empty, the space may be single or more, or a honeycomb structure, and this situation is more common in perianal suppurative hidrosadenitis
(Fig.5.6). Anal stula suppurative sweat adenitis
is often accompanied by anal stula.
The Relationship Between theLocation
oftheExternal Opening andtheTrend
andType ofAnal Fistula
1. Salmon’s Law: when a horizontal line is
drawn in the center of the anus, if the outer
opening of the stula is in front of the line and
no more than 5cm away from the anus, the
pipe is straight and the internal opening is on
the same dentate line as the external opening.
If the external opening is located behind this
line, the pipeline is more curved, and the
internal opening does not correspond to the
external opening. The internal opening is
mostly located at the middle dentate line
behind the anus (Fig.5.7).
2. Goodsall’s rule: when a horizontal line is
drawn in the center of the anus, if the external opening of the stula is in front of this
line or on the horizontal line of the anus, and
the distance from the anal margin is within
2.54–3.81cm, the pipeline is straight and the
internal opening occupies the area of the
dentate line. If the external opening is behind
the line, the main pipe is bent and the internal opening is behind the middle dentate
line. If the distance between the external
opening and the anal border is more than
2.54–3.81 cm, the main wall bends backward
and medially, regardless of whether the
external opening is in front or behind this
line (Fig.5.8).
In addition, Parks marks eight areas of the
anus and perineum as the center according to
natural anatomy. These are namely the anterior
midline area, left anterior area, left posterior area,
left posterior area, posterior midline area, right
posterior area, right area, and right anterior area.
The area 3–5cm outside the anal fold is called
the inner band, and the area 3–5cm outside the
anus is called the outer band. The lesion is named
52
Curved fistula
a
When palpating an anal fistula, slide the finger
to palpate the cord-like fistula
R. Shi and L. Liu
Straight fistul
Curved fistula
External opening
Fig. 5.8 Goodall’s rule
Internal
opening
Internal
opening
External opening
according to its location, such as the right external stula, left posterior internal stula, etc. For
example, if the stula is located in the inner band,
the direction of the pipeline is radial and vertical;
most of the inner bands are located in the corresponding anal recess, and most of the anal stulas in the inner band are conned to the anterior
anal region. If the external opening of stula is
located in the external band, the tube is curved,
and most of the internal opening is located in the
posterior midline area.
5.1.2.2 Palpation
Palpation has a special signicance for the diagnosis of anal stula. Through palpation, the
direction of the anal stula, the position and
number of stula, the relationship between the
stula and the sphincter, the integrity of the anorectal ring, and its elasticity can be directly
detected. The methods of palpation in anal stula
can be generally divided into the following.
External Anal Palpation
External palpation of the anus should be performed by way of sliding palpation, that is, pressing the nger on the perianal skin and slowly
sliding to feel the changes of subcutaneous tissues, stulas, and other lesions (Fig. 5.9).
tips
Fig. 5.9 Palpation of anal stula
Anesthesia will affect the accuracy of palpation,
so palpation should be carried out before anesthesia. Apply parafn oil or grease to gloves
before palpation.
During the attack of anal stula, the lesion site
is repeatedly inamed, swollen, and purulent, and
it usually can be hard to the touch and like a tough
cord that leads from the external opening to the
anal cavity. When the larger mass can be touched
below the external opening of anal stula, the
presence of purulent cavity is more suggestive.
Anal stula pipeline is often relatively small when
anal stula rarely attacks. However, the sensation
of hard cord in the pipeline is often not obvious
when tuberculous anal stula is palpated.
If several external openings are located on the
same side or the opposite side of the anus, the
pipeline often has branches; one should pay
attention to touch the branch and its direction.
When anal stula occurs repeatedly because the
lesion area is often hard and tough and uneven, it
is difcult to know the branch and direction of
the pipeline, so care and experience are needed.
In low anal stula, because of its shallow position, the boundary between the hard cord and the
surrounding tissue is obvious, so it is easy to be
touched. However, because of the high anal stula’s deep pipeline, external anal palpation is
often not satisfactory, it is often difcult to touch
the deep hard cord, and only the isolated indentation of the external opening area can be felt.
5 Common Methods ofExamination forAnal Fistula
53
Anal Internal Palpation
After anal external palpation, the internal anal
palpation is performed. After the nger is inserted
into the anus, it should touch the areas from shallow to deep to further understand the direction of
the stula, the location of the internal opening,
the relationship between the stula and the anal
sphincter, and the integrity and elasticity of the
anorectal ring.
1. The Path and Direction of the Fistula
The direction of the stula is determined
according to the extension of stula in external palpation of the anus, and the stula direction in the anus is further explored during
internal palpation. The posterior anal stula
often extends upward in the back of the anus
and then extends to both sides in the anorectal
ring plane, forming a high horseshoe stula.
In some cases, the stulas extend upward to
the high muscle or submucosa, where there
may be strips of cable in the high muscle or
submucosa, and some of the ends are enlarged
or irregularly upheavaled.
2. The Internal Opening
The internal opening of anal stula is
mostly located in the dentate line, digital rectal examination can touch the denite small
knot in the dental line, and most patients have
signicant palpitation pains. The internal
opening of simple anal stula is mostly in the
same position as the external opening in the
dentate line of the anal canal. The internal
opening of horseshoe stula is mostly in the
posterior median dentate line of the anal
canal. The recurrent anal stula is hard at the
internal opening; the hard knot is large and
easy to be touched. The anal stula soon after
the formation of an abscess is not obvious,
and it is not easy to be touched.
Under anesthesia, the scleroma of the
internal opening of many anal stula patients
is often not obvious; however, the scleroma of
the internal opening is obvious before anesthesia, so palpation examination and positioning of the internal opening are best performed
before surgery. If other examination methods
such as intraoperative probe fail, clamp the
external opening of anal stula or the stula
wall suspected of being the external opening,
pull outward, and touch the position of anal
canal dentate line with the ngers. There is a
traction feeling accompanied by depression of
traction position or depression of traction
position seen under an anal microscope, and
this can be considered as the location of the
internal opening.
3. Anorectal Ring
Attention should be paid to the elasticity
and integrity of the anorectal ring when touching the high anal stula. When the anorectal
ring becomes hard, physicians can use their
ngers to hook the anorectal ring backward
and instruct patients to contract and relax the
anus. If the anorectal ring has good adaptability and strong contraction, it suggests that the
anorectal ring has good elasticity and function. If the anorectal ring cannot arbitrarily
relax and contract or has poor adaptability,
this indicates that the anorectal ring is hardened, the elasticity is poor, or the scar tissue is
large, or there is a stula that is hardened and
thick.
When the anorectal ring is defective or
incomplete, it indicates that the previous anorectal surgery may have caused great damage
to the anorectal ring, and it is necessary to
avoid and minimize further damage to the
anorectal ring during the re-operation so as to
avoid further aggravating the injury and further damaging anal function. If the anus function is incomplete, no further surgery should
be carried out.
Bimanual Examination
Sometimes, when simple palpation outside the
anus or nger examination inside the anus is not
satisfactory alone, the overall appearance of the
anal stula can be grasped by palpation outside
the anus and inside the anus at the same time, and
by the subtle sense of the position and shape
change of the stula perceived when ngers
touch each other inside and outside. This kind of
examination method is usually better than the
simple examination or palpation of the anus with
ngers alone.
54
5.1.2.3 Probe Examination
The purpose of probe examination is to clarify
the relationship between the path, length, depth
of the stula, the relationship of anal sphincter,
and the position of the internal opening. Since the
probe is prone to cause pain during examination,
it should be fully explained to the patient before
examination to explain its importance so as to
obtain patient cooperation.
The probe is made of silver alloy, copper,
stainless steel, and other alloy materials. The
probe has different shapes, and the ball-head rod
probe is often used to examine the stula and its
internal opening. A sickle-shaped grooved wire
hook probe is often used for intraoperative wire
hook. There are also sickle probes with blades
that can be used to probe and open stulas
directly.
When inspecting, apply lubricant to the glove
or nger sleeve, and insert the index nger of one
hand into the anus, the other hand should take the
appropriate probe depending on the thickness
(usually using a silver or aluminum alloy ballshaped rod probe), based on the initial impression
of the stula obtained by visual palpation. The
probe is to be gently inserted into stula along
the direction of the stula, and the stula is gently penetrated. Through perception and guidance
with the nger in the anus, the direction of the
tube, the location of the internal opening, whether
the inner port is unobstructed, and the relationship and distance between stula and muscle tissue are explored (Fig.5.10).
In the process of exploration, the pipe should
be gently plunged into the direction of the stula,
the action should be as meticulous and gentle as
possible, and it should not be harsh to prevent
perforation or articial openings. The examination should ensure that the patient does not feel
obvious pain, and there should be no bleeding.
During the exploration, the probe direction
should be repeatedly adjusted according to the
direction of stula. If there is resistance, the
probe should be withdrawn, and the bending
degree should be adjusted properly before further
exploration. If the bent part of the probe cannot
be penetrated into the entire stula after repeated
adjustment, it may be due to tube narrowness or
R. Shi and L. Liu
Fig. 5.10 Anal stula detection method
occlusion, and no forced forward exploration is
to be allowed.
For complicated anal stula with a deep stula
location and a long stula, it is sometimes difcult to reach the bottom with a probe. In this situation, probes can be inserted from different
external openings for exploration at the same
time. For example, if the probe touches somewhere in the pipeline, it indicates that the
branches of stula converge here and the two
external openings are connected. When the probe
is inserted into the anus through different external openings, experienced doctors can easily perceive the relationship between the probes and the
path and the position of the stula through the
touch of the nger placed in the anus.
5.1.2.4 Anoscope Examination
Tube andHorn Anoscope
Before examination, ask the patient to empty the
stool. The surgeon holds the handle of the anal
mirror in the left hand and use the thumb to press
the core. The mirror body and the head of the
anal mirror are coated with parafn oil, and the
right hand should assist in exposing the anus.
First, gently massage the anal edge with the top
of the anoscope, and ask the patient to open the
mouth to breathe, so that the anus is relaxed.
Then, insert the anoscope slowly into the anus.