What is anal fistula and how to cure fistula in ano
What is an anal fistula?
An anal fistula is an abnormal connection between the epithelialised surface of the anal canal and (usually) the perianal skin.
Anal fistulae originate from the anal glands, which are located between the two layers of the anal sphincters and which drain into the anal canal. If the outlet of these glands becomes blocked, an abscess can form which can eventually point to the skin surface. The tract formed by this process is the fistula.
Abscesses can recur if the fistula seals over, allowing the accumulation of pus. It then points to the surface again, and the process repeats.
Anal fistulas per se do not generally harm and they often do not hurt, but they can be irritating because of the pus-drain (and, it is not unknown for formed stools to be passed through the fistula); additionally, recurrent abscesses may lead to significant short term morbidity from pain, and create a nidus for systemic spread of infection.
Surgery is considered essential in the decompression of acute abscesses; repair of the fistula itself is considered an elective procedure which many patients elect to undertake due to the discomfort and inconvenience associated with a draining tract.
A fistula in ano is a tunnel like- pipe like track, developed in the perennial region, usually having one or more external openings around the anus leading to an internal opening in the mucosa of the anal canal or the rectum.
Anal fistula is termed “Bhagandara” in Ayurveda. In Ayurveda fistulas, like other diseases have been classified according to the vitiation of one per more of the three doshas i.e. the vata, the Pitta & the kapha. They have been classified also according to the shape & site of the track of the fistula. Special treatment for such different kinds of fistulas is mention in detail. It is worth noting that the complex & most challenging horse shoe fistula ( complex Ischio-rectal fistula) has been dealt with in detail in Sushruta a classical Ayurveda text) even as early as 300 ad.
The Ksharsutra treatment was probably first advised per this type of fistula named Parikshepi Bhagandara by Sushurta. This Ksharsootra treatment, with a little modification has proved its worth even in modern times.
Anal fistula, a rare condition, is a chronically inflamed, abnormal tunnel between the anal canal and the outer skin of the anus. It often drains watery pus, which can irritate the outer tissues and cause itching and discomfort.
How does it occur?
An anal fistula usually results from an infection that forms in the tissue lining the anal canal. The infection may be caused by spread of bacteria that normally exist in the rectum. Occasionally, it may occur as a result of :
- A healed sore in the rectal area
- Ulcerative colitis, a disease associated with ongoing breakdown of tissues that causes a sore in the lining of the colon
- Diverticulitis, inflammation of harmless growths in the wall of the intestines
- Crohn’s disease, a chronic inflammation of the intestines
- Tuberculosis
- Gonorrhea
- Cancer of the large intestine.
What are the symptoms?
Symptoms of anal fistula may include :
- A patient of fistula in ano often suffers from a recurrent, small or large boil/boils/abscess surrounding the anus, accompanied with pain, discomfort & pus/blood discharge.
- The symptoms subside when the boil / abscess burst spontaneously causing some more discharge for a couple of days.
- The boil / abscess “heals up” temporarily but almost always reappears after some times.
Itching, discharge of watery pus, irritation of tissue around the anus, discomfort & pain these are the main symptoms of the fistula in ano
Other Symptoms
Anal fistulae can present with many different symptoms:
- Pain
- Discharge - either bloody or purulent
- Pruritus ani - itching
- Systemic symptoms if abscess becomes infected
Diagnosis
Diagnosis is by examination, either in an outpatient setting or under anaesthesia (referred to as EUA - Examination Under Anaesthesia). The examination can be an anoscopy.
Possible findings:
- The opening of the fistula onto the skin may be seen
- The area may be painful on examination
- There may be redness
- An area of induration may be felt - thickening due to chronic infection
- A discharge may be seen
- It may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula
How is it diagnosed?
- To diagnose an anal fistula, the doctor will review your symptoms, give you a physical exam, and may use the following procedures:
- Anoscopy / Proctoscopy , a procedure in which the doctor inserts an instrument called an anoscope into the rectum to inspect the anus and lower part of the rectum
- Probing examination: a procedure in which the surgeon insert an instrument called anal probe it to the external fistulous opening to internal fistulous opening . (see photograph )
- Sigmoidoscopy , a procedure in which a doctor uses a flexible or rigid scope to inspect the lower part of the intestine for inflammation and/or disease
- A biopsy to evaluate for inflammation or cancer
- Lower gastrointestinal (gi) series, a procedure that uses a special fluid to show the intestines better on x-ray
- A lower gi series requires a clean, clear gi tract. The doctor will prescribe a special diet, including plenty of water, for the day before the procedure. In addition, you may be given an enema the morning of the procedure.
Causes
- In a few cases there is a previous history of ano-rectal abscess.
- Some times a fissure in ano/ anal fissure gets infects & the infection travels down to form a track or a fistula.
However in most cases there are no definite causes found.
Possible contributing factors
- Tearing of the lining of the anal canal.
- Infection from an anal gland
- Chron’s, ulcerative colitis, tuberculosis
Guide lines to approach an expert for investigating a possibility of anal fistula.
Recurrent boils developing at the same site. (around the anus)
- Burning sensation or pain in perennial region
- Pus discharge /blood discharge in perianal or from the anus.
Treatment
There are several stages to treating an anal fistula:
Treating active infection
Some patients will have active infection when they present with a fistula, and this requires clearing up before definitive treatment can be decided.
Antibiotics can be used as with other infections, but the best way of healing infection is to prevent the buildup of pus in the fistula, which leads to abscess formation. This can be done with a seton - a length of suture material looped through the fistula which keeps it open and allows pus to drain out. In this situation, the seton is referred to as a draining seton.
Definitive treatment
Definitive treatment of a fistula aims to stop it recurring. Treatment depends on where the fistula lies, and which parts of the anal sphincter it crosses.
There are several options:
- Doing nothing - a drainage seton can be left in place long-term to prevent problems. This is the safest option although it does not definitively cure the fistula.
- Lay-open of fistula-in-ano - this option involves an operation to cut the fistula open. Once the fistula has been laid open it will be packed on a daily basis for a short period of time to ensure that the wound heals from the inside out. This option leaves behind a scar, and depending on the position of the fistula in relation to the sphincter muscle, can cause problems with incontinence. This option is not suitable for fistulas that cross the entire anal sphincter.
- Cutting seton - if the fistula is in a high position and it passes through a significant portion of the sphincter muscle, a cutting seton may be used. This involves inserting a thin tube through the fistula tract and tieing the ends together outside of the body. The seton is tightened over time, gradually cutting through the sphincter muscle and healing as it goes. This option minimizes scarring but can cause incontinenceflatus (wind). Once the fistula tract is in a low enough position it may be laid open to speed up the process, or the seton can remain in place until the fistula is completely cured. in a small number of cases, mainly of
- Fibrin glue injection is a method explored in recent years, with variable success. It involves injecting the fistula with a biodegradable glue which should, in theory, close the fistula from the inside out, and let it heal naturally. This method is perhaps best tried before all others since, if successful, it avoids the risk of incontinence, and creates minimal stress for the patient.
- Fistula plug is an “advanced” version of the fibrin glue method. It involves “plugging” the fistula with a “plug” made of porcine small intestine submucosa (sterile, biodegradable), fixing the plug from the inside of the anus with suture, and, again, letting the fistula heal “naturally” from the inside out. According to some sources, the success rate with this method is as high as 80%.
- Endorectal advancement flap is a procedure in which the internal opening of the fistula is identified and a flap of mucosal tissue is cut around the opening. The flap is lifted to expose the fistula, which is then cleaned and the internal opening is sewn shut. After cutting the end of the flap on which the internal opening was, the flap is pulled down over the sewn internal opening and sutured in place. The external opening is cleaned and sutured. Success rates are variable and high recurrence rates are directly related to previous attempts to correct the fistula.
- Anal Fistula Plug is a recently developed method known as AFP. This treatment requires placement and fixing of a plug in the anal fistula by a special technique. One advantage of this method is that it involves no cutting, so there is no post operative wound and pain. AFP plugs can sometimes be inserted under local anesthesia. This method can be used successfully to treat high fistula without colostomy. It does not carry any risk of bowel incontinence. As opposed to the staged operations, which may require multiple hospitalizations, AFP requires hospitalization for only about 24 hours. Currently, there are two different anal fistula plugs cleared by the FDA for treating ano-rectal fistulas in the United States.
Other Modes of treatments
Anal fistulas are almost never found to heal spontaneously. The inner wall of the fistula develops fibers tissue & payogenic membrane not allowing spontaneous healings.
- The most commonly followed mode of treatment is laying open the entire track of the fistula and removing the fibrous tissue & payogenic membrane. This sometimes, in complex fistulas is done in two or more sittings. In certain cases a silk setone is passed through parts of the track. (see detail )
- The Ksharsutra / Ksharsootra ( Medicated Setone ) Ligation.
- Laser Surgery ( Fistulectomy / fistulectomy by laser beam )
- Laying open the fistula and applying a skin graft.
- Laying open, excision of the fistulous track and suturing the wounds.
- Coring out the fistulous track. ( link with core technique for fistula )
- Sealing with fibrin glue.
Ayurveda has a unique way of treating fistula in ano. Simple as well as complex fistulas, high anal fistulas, fistulas with multiple track, recurrent fistulas, chron’s fistula, tubercular fistula, all respond well to the Ksharsutra ligation procedure.
What is Ksharsutra / Ksharsootra?
The Ksharsootra /Ksharsutra is a type of thread / medicated setone prepared by coating and recoating the thread 15 to 21 times with different drugs of plant origin. The mechanical action of the treads and the chemical action of the drugs coated on the thread, to gather do the work of cutting, curetting, draining, and cleaning the fistulous track, thus promoting healing of the track/ wound.
And natural antibiotic like haridra powder, guggulu, etc are used in the preparation of different kind of Ksharsutra. It takes a number of days to prepare this Ksharsutra since the previous coat has to dry before the next is applied.
Different kinds of Ksharsootra are prepared using different drugs. These Ksharsutra are passed through the track (usually under short anesthesia) and the two ends of the thread are tied forming a loop. The drugs coated on the thread are continually released through out the length of the track there by cutting, curetting, draining cleansing and healing the track simultaneously in the track after about eight days the thread loosens because it has cut through some of the tissues and also is now almost bare ( with no drugs on it). A new thread is now replaced in the track by a special method. The changing of the thread is a simple opd procedure taking about 1 to 2 minutes and requires no anesthesia. (See the procedure). the thread gradually cuts through the tissue. The tissues above the thread heal up. Hence when at last the loop of thread comes out, the track is healed.
Ksharsootra (medicated setone) therapy is practiced in India since times immemorial. Modified and revived by the late Dr. P. J. Deshpande. The Ksharsootra therapy is a unique treatment of Ayurveda gaining popularity globally.
Special types of medicated setone are used in this procedure Found to be effective in any ano rectal conditions, it has many advantages in the treatment of Anal fistulae.
Benefits of the ksharsutra ligation procedure over other methods
The Ksharsootra ligation method is an age old, time tested procedure originally performed by Sushruta (the father of surgery) around 300 ad. The fact that it is still in practice to day is a proof in it self of its efficacy.
- The Ksharsutra procedure is performed under short acting anesthesia / local anesthesia and some times even without anesthesia.
- The procedure usually dose not require hospitalization for more than 4 to 5 hours.
- The patient requires minimal bed rest & can resume his / her daily routine within 12 to 24 hours.
- It gives freedom from pain full dressings.
- There is no loss of glutial mussels and hence the anatomy of the peri anal region is not distorted.
- The procedure lives just a pencil scar at the site.
- The recurrence rate which is usually found to be quite high after other methods is less than 2% after Ksharsutra ligation procedure. This is because the medicines on the thread gradually and continually curate the payogenic membrane and fibrous tissue in the track and thus leave no pus pockets un drained.
- Chances of partial or complete incontinence of flatus or / and faces (loss of control of passing stool / flatus) are always present in many types of fistula, (especially in fistulae involving the sphincter muscles after the conventional procedure. ( Fistulectomy Fistulotomy ). There are no chances of developing incontinence in Ksharsutra ligation method.
How can i take care of myself ?
- Using stool softeners
- Adding fiber to your diet
- Drinking plenty of water, up to 8 eight-ounce glasses a day
- Taking warm baths
- Using clean, moist pads to wipe the area around the anus, to remove irritating particles and fluid from the fistula
- Using special skin creams to soothe irritated tissue.
- How can i help prevent an anal fistula?
- Follow these guidelines to help prevent an anal fistula. They help to keep the lower gastrointestinal tract healthy.
- Eat food high in fiber.
- Drink plenty of water each day (up to eight 8-ounce glasses).
- Have regular physical exams to look for underlying diseases of the rectum.
- Be aware of the signs and symptoms of bowel disease, and seek medical attention if any appear.
when i take antibiotics… it can cure my perrenial abcess permantly?
I had a couple of operations to lay open the fistula and then let it heal from the inside-out. Discomfort for a few weeks after surgery, especially after bowel movement, as you need to make sure you keep the wound clean and dry. Quite ghastly if you can see the wound as it is cut right open to ensure both ends are completely cleaned. But it permanently healed up for me so it was worth the pain and hassle!
i was diagnosed to have a fistulae and the doctor recommended me for surgery but i declined because im not sure if it is 100% treatment. does ignoring fistulae will not form or result in any serious diseases?
Thank you.
@STEVEN: How much did it cost your operation, and where did you get the treatment?
i am really interested about kshara sutra.is it really a successful procedure for healing complex fistula? please answer to my mail adress.
What is the difference between the fitula plug and the AFP? They sound like the same thing, is one procdure better then the other?
Where is fistula plug surgery available in navi mumbai. pls answer to my mail address.