Anal Fistula - Causes, Symptoms, Diagnosis, Treatment, Recovery

What is Anal Fistula?

An anal fistula is a tunnel that runs from the anal opening and connects the skin around it. An anal fistula mostly forms after an infection that did not heal properly. In human anatomy, the external opening through which feces are expelled is known as the anus. Multiple small glands that make mucus are located inside the anus. When these glands get clogged and infected due to dirt and debris, it can lead to the formation of an abscess. Most of these abscesses turn into an anal fistula.

Causes and Symptoms of Fistula

Causes of Fistula

• Trauma to the anal tissues
• Infection in the anal gland
• Radiation from cancer treatment
• Crohn’s disease
• Sexually transmitted disease
• Tuberculosis
• Diverticulitis
• Cancer

Symptoms of Fistula

• Pain and swelling around the anus
• Frequent anal abscesses
• Foul-smelling bloody drainage from anal opening
• Bleeding along with stool
• Pain during bowel movements
• Fever, chills and fatigue

Risks & Complications of Fistula

During the Surgery

Like any other surgical treatments, there are potential risks and complications associated with surgery if anal fistula too. Common complications may include:

Infection – When incisions are made in the skin, every surgery carries some risk of infection. The same is with the procedure of fistulectomy. In certain cases, where the fistula tract is too deep, the doctor might need to perform the surgery in several stages. In that case, there is a high possibility that the fistula might spread throughout the body and cause systemic infection. In case of infection from anal fistula, the doctor might prescribe antibiotics. If the infection is too severe, the patient might even require to be admitted to a hospital and undergo intravenous administration of antibiotics.

Bowel Incontinence – If the fistula surgery is not performed by an expert anorectal surgeon, there are chances that the anal sphincter muscles may get damaged. The anal sphincter muscles are responsible for keeping the anus and controlling the bowel movements. In any case, if the sphincter muscles are damaged, the strength of the anal muscles is compromised which may cause leakage of feces. This condition is known as bowel incontinence. Bowel incontinence is estimated to affect 3-7 percent of the total patients who undergo anal fistula surgery.

Anal Fistula Recurrence – An estimated 7-21 percent of patients who have undergoes surgery for anal fistula suffer from recurrence of anal fistula after surgery. The chances of recurrence is ten highest in the case of treatment of anal fistula through fibrin glue.

When Left Untreated

If you are diagnosed with any anorectal disease including anal fistula, it is always better to undergo treatment without delay. In the words of a senior proctologist at Pristyn Care, “Home remedies should not be relied for long duration if you have been diagnose with anal fistula or any other anorectal disease. Home remedies can only help reduce the severity of symptoms such as pain, swelling, soreness, redness, and inflammation in the anal region. For a permanent cure, undergoing surgery is the only safest and best method.”

If left untreated, anal fistula can lead to the following complications:

1. Unbearable pain – Untreated fistula-in-anal can cause severe and unbearable pain in the anal area. The pain can get worse with time and even the condition might be complex to treat.  An untreated anal fistula is likely to cause foul-smelling anal discharge that can hamper your lifestyle and make you feel embarrassed.
2. Unable to sit or walk – Diseases like anal fistulas can make you feel uncomfortable while sitting and walking. So, it is advised to undergo surgery as soon as you are diagnosed with any of them.
3. Extension of anal fistulas – An untreated anal fistula can extend into the internal anal sphincter muscle that holds your anus closed. In such cases, it is difficult to heal the fistula and can cause severe pain and discomfort that would require medication therapy along with surgical intervention.

Complications that can be caused as a result of delayed treatment for anal fistulas may also include:

• Sharp pain during bowel movements
• Burning and itching sensation in and around the anus
• Leakage of pus from the anus
• Formation of skin tags or lumps at the anal area
• Development of anal ulcers.

Recovery Timeline of Fistula Surgery

The healing capacity of every person is different and hence the timeline of recovery after anal fistula surgery varies for all. In most cases, recovery after open surgery for anal fistula takes around 2-3 months and complete recovery after laser surgery takes 1 month to 45 days.

Recovery after 1 month

For at least 1 month after anal fistula surgery, the patient needs to follow the recovery tips and recommendations by the doctor. It is advisable that the patient refrain from doing anything that puts strain on the surgical site. The patient should not eat anything too oily and spicy and consume only fiber-rich food. The patient should keep the surgical area free of any infection and take regular sitz baths.

Recovery after 2 months

After 2 months, the patient would experience much relief from the pain at the surgery site. But the scars might take some more time to disappear. The patient might get back to normal work life without any major complications and also resume normal dietary habits.

Recovery after 3 months

After 3 months, the patient would be free from all post-surgery discomfort. There would be no scars at the surgical site and the wound would be healed completely too.

How Does Anal fistula form?

When the abscesses that form near and around the anal mucosal tissues are not treated, it tends to keep growing and worsening over time. Eventually, the abscess punches out like a hole making its way outside the skin.

When to Consult a Doctor for Anal Fistula?

Most people tend to ignore the early symptoms of anal fistula. Not knowing the symptoms of the disease can make you ignorant of the facts as to when to approach the right doctor. Getting medical treatment and professional help can help you avoid timely complications of the condition. If you experience any of the following signs, it could be an indication of an anal fistula. Without further delay, you should consult with an anorectal surgeon in that case:

• If you see/ notice a foul-smelling discharge from your anal area.
• If you see blood in your stool or blood in the toilet seat/ tissue paper, consult with a doctor at the earliest. Blood in the stool can be a common sign for most anorectal disease and not fistula-in-ano alone. Hence, this symptom needs to be discussed with the doctor to evaluate the condition and to determine the best line of treatment.
• When no medication and home remedies provide you relief or effective results from your symptoms.

Treatment options, Cost and Insurance Coverage of Fistula Surgery

Non-surgical treatments for anal fistula

1. Fibrin glue – Fibrin glue is a therapeutic for anal fistulas which activates thrombin to form a fibrin cloth. The procedure helps close the fistula tract mechanically. Fibrin glue is a liquid sealant thought to assist in fistula tract healing by stimulating migration and activation of fibroblasts.2 It is a tempting treatment modality: the technique is simple, repeatable, and involves only minor surgical trauma to the anal sphincter. Fibrin glue treatment is very easy to use and is considered as a good treatment for people who are not in favor of surgery. However, fibrin glue is not the best replacement for skilled anorectal surgery.
2. Seton placement – This procedure involves placing a suture or a rubber band (also known as seton) in the anal fistula that is progressively tightened. The rubber band lets the fistula heal behind the seton. The treatment is non-invasive and the risk of recurrence is also quite low.

Surgical treatments for anal fistula

Once you have developed anal fistula, antibiotics or home remedies alone will not cure the condition. You will require surgical intervention to get the condition treated. Surgical options for anal fistula treatment include:

• Fistulotomy – In this treatment, the fistula is opened and allowed to heal from the inside out. The surgery is usually an outpatient procedure. As such, the patient can return home the very same day.
• Laser surgery for anal fistula –  Laser treatment for the closure of fistula-in-ano is a minimally invasive and low-complication treatment which is considered as the most effective treatment for complex fistulas. The treatment does not cause any severe damage or injury to the sphincter muscles.

Home remedies for anal fistula

There’s no denying that if you have developed anal fistula, the best thing to do is get professional help. Additionally, you can include self-care measures in your daily regime that may not only aid in reducing the symptoms but also help the fistula heal in a much shorter time.

Sitz baths – Sitz baths is one of the highly beneficial home remedies for almost every anorectal problem including anal fistula. Sitz baths may help in not only relieving pain of the anal area but also speed up the healing process. Sitz bath is basically feeling a plastic tub with warm water and soaking your anal area for 15-20 minutes in the water. The tubs used for the treatment can be brought from any drugstore. You can add Epsom salts and additives in the water too, but only after a recommendation from your healthcare provider.

Eating more fiber – If you have any anorectal disease or disorder, eating a sufficient amount of fiber may help prevent stools from being hard and prevent constipation and diarrhea. Fiber-rich diet can aid you in passing stools easily which may be less traumatic to the anal opening. Some examples of fiber-rich food are:

• Beans
• High-fiber bran cereal
• Split peas
• Chickpeas
• Lentils
• Pigeon peas
• Wheat bran flakes
• Avocados
• Soybeans

Use stool softeners – Using stool softeners may prevent complications such as constipation. Stool softeners usually are quite effective in case of any anorectal diseases and cause no side effects. Stool softeners pull more water into the digestive tract which softens the stool. However, most doctors do not recommend using stool softeners for more than a week or ten days. Once you stop using stool softeners, it is important that you make lifestyle changes and continue healthy food.

Take care of the perianal skin – Do you want to prevent or manage anal fistula? The trick is to keep your perianal skin clean after bowel movements. If the jet spray is hurting your skin, you can skin the area with wet wipes. Make sure to rub or pat dry the area after passing stool each time. Remember to be gentle with your skin.

How to prepare for anal fistula surgery?

Anal fistula surgery is not a very complicated treatment and as such requires no thorough preparation. The preparation is even simpler in the case of laser surgery for anal fistula. But like any other surgery,  of complications/ side effects in case of surgery for anal fistula too. Hence, you need to follow the doctor’s instructions to ensure that your surgery goes well and you recover without any complications. Before your surgery for anal fistula:

• Do not eat or drink anything heavy. Eat a very light meal, preferably only breakfast.
• Do not drink any form of carbonated or caffeinated drinks, just consume clear liquids at least for 5 hours before the surgery.
• If you are on any anti-inflammatory, allergy medicines, or blood thinners, the doctor will recommend you stop it as soon as possible before the treatment.
• Stop smoking and drinking alcohol. It will help you heal faster after the surgery.

How to recover after anal fistula surgery?

The recovery route after anal fistula surgery is usually simple with no major complications. If you diligently follow the doctor’s recommendations and tips, you will not experience any complications. Here are a few tips that can help you heal and recover easily after anal fistula surgery:

• Eat a high-fiber diet.
• Avoid lifting heavy weights.
• Use a stool softener that can aid you in having smooth bowel movements.
• Stay hydrated. Drink at least 8-10 glasses of water every day.
• Do not strain while passing a stool.

Insurance coverage

Anal fistula treatment is generally covered under health insurance. Most insurance companies offer a specific amount of coverage for anal fistula and other anorectal diseases. The amount of coverage you have will depend on the policy you buy.

One thing you should know is that medical treatment for anal fistula won’t be covered in the insurance policy. Only the expenses of surgical treatment are covered and you also need to be hospitalized for at least 24 hours to file for a claim. You can opt for cashless payment or get reimbursement claims from your insurance providers as well.

If your claim is approved, you will be able to cover the entire cost of treatment, including diagnostic tests, medications, hospital stay, bed charges, and other consumables. Some of the best and most popular healthcare insurance providers are Oriental, Religare Health, Manipal Cigna, United India Insurance, Care Health, New India Insurance, Star Health & Allied, Bajaj Allianz General Insurance, ICICIA Lombard, Max Bupa Health Insurance.

Diagnosis - Tests, Self Diagnosis and Diagnosis by Doctor

Test

In most cases of anal fistula, the anorectal specialist is able to diagnose it just through a physical examination. In case the condition of the anal fistula is severe, the doctor might require to do an examination of your rectum and anal canal. The commonly performed tests to diagnose anal fistula are:

Digital examination – In this test, the fistula specialist inserts a gloved, lubricated finger into the rectum to check if there are any kind of abnormal growths.

Visual inspection – The proctologist or the anorectal surgeon might examine the lower rectum using a proctoscope, an anoscope or a sigmoidoscope. Using any of these devices, the doctor will carefully examine the lining of your anal tissues to check the severity and depth of your anal fistula.

Anoscopy – Anoscopy allows the anorectal doctor to examine the inner lining of your anus and rectum. The test checks for abnormal growths, bleeding, inflammation, and conditions such as diverticulosis.

Sigmoidoscopy – Flexible sigmoidoscopy is a useful test to look for underlying aetiology in fistula-in-ano.

Imaging tests – Your physician may also order an ultrasound or MRI of the anal area to get a better view of the fistula tract.

Self Diagnosis

Self-diagnosis of anal fistula is not very difficult if you are well aware of the symptoms. If you think you have hemorrhoids, you can be pretty sure about it by checking the anal area and if there is any abnormality near the anal opening. If you have an anal fistula, you are also to experience constant irritation in your anal skin that can make it difficult for you to sit or sit on the toilet seat. You may also experience smelly and foul discharge from and near your anus, and on rare occasions, you may also pass blood along with your stool. Additionally, there might be swelling and redness in your anal area and you may experience high fever.

Diagnosis by Doctor

Most proctologists or anorectal surgeons diagnose anal fistula through physical examination alone. Once you visit the doctor’s clinic, the doctor may ask you a few questions to understand your condition better and to determine the best line of treatment.

• Do you have a family history of anal fistula?
• When did you start having the symptoms?
• Do you pass blood with your stool?
• What are your dietary and lifestyle habits?
• What is your fitness regime like?
• When do you feel the pain mostly?

The doctor may also do a digital rectal examination to diagnose the severity of the fistula tract and to locate the internal openings. The proctologist may also suggest tests like colonoscopy, sigmoidoscopy, and anoscope to check for the presence of any gastrointestinal disease. In these tests, the doctor inserts a small camera to check for any abnormalities in the anus, rectum, and colon. In some cases, the doctor may also suggest flexible sigmoidoscopy to check if there are any secondary branches (one internal opening but multiple external openings) of the fistula.

Prevention of Anal Fistula

Here are some of the tips that can help you prevent anal fistula:

• Consuming a high-fiber diet – One of the easiest ways to prevent anal fistula is to prevent the passing of hard stools. To prevent hard bowel movements, the best thing to do is stock up your diet with fiber-rich food. If you want to avoid getting anal fistula, it is crucial to eat at least 25-30 grams of fiber per day. Some foods rich in fiber are:
  • Whole grains, oatmeal, and brown rice
  • Beans and lentils
  • Vegetable and Brussels sprouts
  • Fruits such as bananas, apples, pears, and berries
• Drink sufficient water – Water along with a fiber-rich diet is very important for the prevention of any anorectal disease. Drinking enough water prevents constipation and hard stools which in turn decreases the need to strain while passing a bowel movement. To prevent anal fistula, drinking enough water throughout the day is extremely important. It will help your digestive system function properly.
• Maintain cleanliness and dryness in your anal region – Anal fistula often forms as a result of clogs and blockages in the anal canal. Long-term accumulation of dirt and debris leads to the formation of anal fistula. To prevent this, it is crucial to clean the anal area every time you pass a bowel movement. Don’t leave the area wet after cleaning, pat it well and dry so that there are no bacteria or infections.
• Don’t strain while passing stool – Do not strain while making bowel movements.  Straining can make the condition of the anal skin worse and lead the anal fistula to aggravate in nature. It is equally important to take care that you don’t spend long hours sitting on the toilet seat. The longer you sit on the toilet seat, the more you are likely to strain while making your bowel movements worse.
• Regular exercises – Almost all anorectal diseases have a direct relation to physical activities and how you keep your body active. Staying physically active keeps the colon active and functions in a regular manner. But that being said, you should know which exercise is good for you and which is not. Avoid any activity that puts strain and pressure on your abdominal region. Do not lift weights. Do not sit in one place for long hours. Indulge in moderate physical exercises regularly.

Recovery Timeline of Fistula Surgery

The healing capacity of every person is different and hence the timeline of recovery after anal fistula surgery varies for all. In most cases, recovery after open surgery for anal fistula takes around 2-3 months and complete recovery after laser surgery takes 1 month to 45 days.

Recovery after 1 month

For at least 1 month after anal fistula surgery, the patient needs to follow the recovery tips and recommendations of the doctor. It is advisable that the patient refrain from doing anything that puts strain on the surgical site. The patient should not eat anything too oily and spicy and consume only fiber-rich food. The patient should keep the surgical area free of any infection and take regular sitz baths.

Recovery after 2 months

After 2 months, the patient would experience much relief from the pain at the surgery site. But the scars might take some more time to disappear. The patient might get back to normal work life without any major complications and also resume normal dietary habits.

Recovery after 3 months

After 3 months, the patient would be free from all post-surgery discomfort. There would be no scars at the surgical site and the wound would be healed completely too.