Symptoms of an anal fistula

There are several common symptoms of an anal fistula.

Symptoms include:
skin irritation around the anus (the opening where waste leaves the body)
a throbbing, constant pain that may be worse when you sit down, move around, have a
bowel movement or cough
a discharge of pus or blood when you have a bowel movement
If your fistula was caused by an abscess that you still have, you may have:
a high temperature of 38C (100.4F) or over
fatigue
a general feeling of being unwell
If your fistula was caused by inflammation of the intestines (part of your digestive system), for
example because of a condition such as irritable bowel syndrome or ulcerative colitis, you may
also have:
abdominal pain
diarrhoea
loss of appetite
weight loss
nausea (feeling sick)
vomiting
Causes of an anal fistula
An anal fistula is most commonly caused by an anal abscess. It can also be caused by
conditions that affect the intestines (part of your digestive system).
Anal abscess
An abscess is a painful collection of pus. An anal abscess usually develops after a small gland,
just inside the anus, becomes infected with bacteria. The cause of the abscess is often unknown,
although abscesses are more common in people with immune deficiencies, such as HIV and
AIDS.
Abscesses are usually treated with a course of antibiotics (medication to treat infections caused
by bacteria). In most cases, you will also need to have the infected fluid drained away from the
abscess.
If an anal abscess bursts before it has been treated, it can sometimes cause an anal fistula to
develop. A fistula may also occur if an abscess has not completely healed, or if the infected fluid
has not been entirely drained away.
Approximately 40% of people with an anal abscess will develop an anal fistula.
Other causes
An anal fistula may also develop as a result of:
a growth or ulcer (painful sore)
a complication of surgery
a health problem you were born with
Anal fistulae are also a common complication of conditions that cause the intestines to become
inflamed, such as:
diverticulitis the formation of small pouches that stick out of the side of the large
intestine (colon), which become infected and inflamed
ulcerative colitis a chronic condition that causes the colon to become inflamed and can
cause ulcers to form on the lining of the colon
Crohn's disease a chronic condition that causes inflammation of the lining of the
digestive system
Other infections or conditions that can lead to the development of an anal fistula include:
cancer of the rectum the rectum is an area at the end of the colon where faeces are
stored
tuberculosis (TB) a bacterial infection that mainly affects the lungs, but can also
spread to many different parts of the body
HIV and AIDS a virus that attacks the body's immune system (its defence against
disease and infection)
chlamydia a sexually transmitted infection that often causes no symptoms
syphilis a bacterial infection that is passed on through sexual contact, injecting drugs or
blood transfusions
Diagnosing an anal fistula
Physical examination
The specialist will examine your anus (the opening where waste leaves the body) and the
surrounding area for any physical signs of a fistula. The opening of a fistula usually appears as a
red, inflamed (swollen) spot, which often oozes pus.
If the opening of the fistula is found, the specialist may be able to work out where the path of the
fistula lies. The path of the fistula can sometimes be felt as a hard, cord-like structure beneath the
skin.
Digital rectal examination
Your specialist will also perform a digital rectal examination (DRE). This involves placing a
finger into your anus. During the DRE, the finger will be covered with a glove and lubricated
with gel.
The DRE allows your doctor to find out where the internal opening of the fistula is, and if there
are any secondary tracts branching off it.
During the DRE, your doctor may ask you to squeeze your sphincter muscles (the rings of
muscles that open and close the anus) around their finger, to assess how well they are working.
The DRE will help determine what kind of treatment you need, or whether further tests are
necessary.
Fistula probe
Your specialist may also need to use a proctoscope (special telescope with a light on the end) to
see inside your rectum. They may also use a fistula probe, which is a tiny instrument inserted
through the fistula.
These examinations may be performed under general anaesthetic, where you are asleep.
Further tests
If you have a complicated fistula with several branches, you may need further tests to determine
the exact position of the fistula tracts. This will help determine your treatment.
Some further tests that may be recommended include:
Anal endosonography (ultrasound) this test uses high-frequency sound waves to
create an image of the inside of your body. This is an accurate and frequently used way of
locating the internal opening of a fistula.
Magnetic resonance imaging (MRI) scan an MRI scan uses strong magnetic fields
and radio waves to produce a detailed image of the inside of your body. This type of scan
is often used in cases of complex or reoccurring fistulae.
Computerised tomography (CT) scan a CT scan uses X-rays and a computer to create
detailed images of the inside of your body. This may be used if you have an
inflammatory bowel disease, such as Crohns disease, as it can be used to assess the
extent of the inflammation.
Treatment of anal fistulas
The type of surgery will depend on the position of your anal fistula. The options include:
Fistulotomy. This is used in 85-95% of cases and involves cutting open the whole length
of the fistula in order for the surgeon to flush out the contents. This heals after one to two
months into a flattened scar.
Seton techniques. A seton is a piece of thread which is left in the fistula tract. This may
be considered if you are at high risk of developing incontinence when the fistula crosses
the sphincter muscles. Sometimes several operations are necessary.
Advancement flap procedures. This option is usually when the fistula is considered
complex, or is there is a high risk of incontinence. The advancement flap is a piece of
tissue that is removed from the rectum or from the skin around the anus. During surgery,
the fistula tract is removed and the flap is reattached where the opening of the fistula was.
The operation is effective in about 70% of cases.
Fibrin glue. This is currently the only non-surgical treatment option. The glue is injected
into the fistula to seal the tract, then the opening is stitched closed. It is a simple, safe and
painless procedure, but long term results for this method are poor. Initial success rates as
high as 77% drop to 14% after 16 months.
Bioprosthetic plug. This is a cone shaped plug made from human tissue, which is used to
block the internal opening of the fistula. Stitches keep it in place. However, this does not
completely seal the fistula, so that it can continue to drain. New tissue usually grows
around the plug to heal the fistula. Two trials show success rates of over 80% for this
method, but long term success rates are uncertain.
Complications of an anal fistula
Complications from an anal fistula are usually the result of fistula surgery. They can
include infection, bowel incontinence or the fistula reoccurring.
Infection
Any type of surgery carries a risk of infection. If the fistula is not completely removed, for
example because you are having the surgery carried out in several stages, an infection in the tract
(channel) can sometimes spread to other parts of the body.
If this happens, you may require a course of antibiotics (medication to treat infections that are
caused by bacteria). If the infection is severe, you may need to be admitted to hospital so that
antibiotics can be administered through a drip in your arm (intravenously).
Incontinence
In some cases, surgery can damage the anal sphincter muscles (the ring of muscles that open and
close the anus). If the muscles are damaged, you may lose control of your bowels, leading to
faeces leaking uncontrollably from your rectum (the area where they are stored). This is known
as faecal or bowel incontinence.
The likelihood of incontinence occurring after surgery will depend on the type of surgery you
had and the position of your fistula. If you had some bowel incontinence before surgery, this may
get worse.
Incontinence after a fistulotomy (surgery that opens up the fistula) is more common in women
and in people with Crohn's disease, a condition that causes inflammation of the lining of the
digestive system. Rates of incontinence vary, although most studies report incontinence in
between 3% and 7% of people.
After using seton techniques, the incontinence rate is 17%, and after an advancement flap
procedure the incontinence rate is around 68%. Ask your surgeon about the risks associated
with your procedure.
Reoccurrence of the anal fistula
In some cases, the fistula can reoccur despite surgery. After having a fistulotomy, the
reoccurrence rate is 21%. After an advancement flap procedure, the reoccurrence rate may be as
high as 36%.

Hemorrhoids
Hemorrhoids are swollen veins in the anal canal. This common problem can be painful, but it's
usually not serious.
Veins can swell inside the anal canal to form internal hemorrhoids. Or they can swell near the
opening of the anus to form external hemorrhoids. You can have both types at the same time.
The symptoms and treatment depend on which type you have.
Many people have hemorrhoids at some time.
Too much pressure on the veins in the pelvic and rectal area causes hemorrhoids.
Normally, tissue inside the anus fills with blood to help control bowel movements. If you strain
or sit on the toilet a long time to move stool, the increased pressure causes the veins in this tissue
to swell and stretch. This can cause hemorrhoids.
Diarrhea or constipation also may lead to straining and can increase pressure on veins in the anal
canal.
Pregnant women can get hemorrhoids during the last 6 months of pregnancy. This is because of
increased pressure on the blood vessels in the pelvic area. Straining to push the baby out during
labor can make hemorrhoids worse.
Being overweight can also lead to hemorrhoids.
The most common symptoms of both internal and external hemorrhoids include:
Bleeding during bowel movements. You might see streaks of bright red blood on toilet
paper after you strain to have a bowel movement.
Itching.
Rectal pain. It may be painful to clean the anal area.
With internal hemorrhoids, you may see bright red streaks of blood on toilet paper or bright red
blood in the toilet bowl after you have a normal bowel movement. You may see blood on the
surface of the stool.
Internal hemorrhoids often are small, swollen veins in the wall of the anal canal. But they can be
large, sagging veins that bulge out of the anus all the time. They can be painful if they bulge out
and are squeezed by the anal muscles. They may be very painful if the blood supply to the
hemorrhoid is cut off. If hemorrhoids bulge out, you also may see mucus on the toilet paper or
stool.
External hemorrhoids can get irritated and clot under the skin, causing a hard painful lump. This
is called a thrombosed, or clotted, hemorrhoid.
Your doctor can tell if you have hemorrhoids by asking about your past health and doing a
physical exam.
You may not need many tests at first, especially if you are younger than 50 and your doctor
thinks that your rectal bleeding is caused by hemorrhoids. Your doctor may just examine your
rectum with a gloved finger. Or your doctor may use a short, lighted scope to look inside the
rectum.
Rectal bleeding can be a sign of a more serious problem, such as colon, rectal, or anal cancer. So
if the first exam does not show a clear cause of your problems, your doctor may use a lighted
scope (sigmoidoscope) to look at the lower third of your colon. Or your doctor may use another
kind of scope (colonoscope) to look at the entire colon to check for other causes of bleeding.
Treatment
Treatments for hemorrhoids include:
Over-the-counter corticosteroid creams to help reduce pain and swelling
Hemorrhoid creams with lidocaine to help reduce pain
Stool softeners help reduce straining and constipation
Witch hazel (applied with cotton swabs) can reduce itching. Other steps to reduce this itching
include:
Wear cotton undergarments.
Avoid toilet tissue with perfumes or colors, use baby wipes instead.
Try not to scratch the area.
Sitz baths can help you to feel better. Sit in warm water for 10 to 15 minutes.
If your hemorrhoids do not get better with home treatments, you may need a type of heat
treatment to shrink the hemorrhoids. This is called infrared coagulation. This may help avoid
surgery.
Surgery that may be done to treat hemorrhoids includes rubber band ligation or surgical
hemorrhoidectomy. These procedures are generally used for patients with severe pain or
bleeding who have not responded to other therapy.
Prevention
Constipation and straining during bowel movements raise your risk for hemorrhoids. To prevent
constipation and hemorrhoids, you should:
Drink plenty of fluids, at least eight glasses per day.
Eat a high-fiber diet of fruits, vegetables, and whole grains.
Consider fiber supplements.
Use stool softeners to prevent straining.