What is a fistula?

A fistula is an abnormal connection between 2 parts of the body. This can occur between a variety of different organs. An example would be a connection between the urine bladder and the bowel.

What is an anal fistula?

An anal fistula is an abnormal connection between the skin around the anus and the lining of the anal canal. This is a tract or tunnel.

Why do they develop?

Anal fistula are usually the result of an abscess around the anus.

How are they treated?

• A fistula may not be associated with any symptoms.
• If this is the case then no treatment may be required.
• However there would be a risk of recurrent anal infection with no treatment. Mostly a fistula will require surgery.
• They will not respond to antibiotics.
• The operations performed are varied and principally depend on the type of fistula. In particular the surgeon will need to assess the amount of anal sphincter muscle involved by the fistula. If too much of this muscle is cut it is possible for there to be reduced bowel control and accident either to flatus or faeces.

Operations commonly performed are:

1. Fistulotomy. This involves cutting open the fistula and creating a wound that is allowed to heal from its raw base to finally heal at the skin.
2. Seton insertion. The word seton is derived from the Greek word for hair. This involves placing a stitch through the fistula and leaving it in place for many weeks. This allows drainage and it will slowly cut through. As it cuts through slowly the muscle is cut, but heals at the same time so that the muscle ring does not spring apart.
3. Advancement flap. This operation involves covering the anal opening of the fistula with the lining of the anus or rectum. If this heals no more faecal contamination of the fistula tract can occur and the fistula will heal.

Fistula in Crohn’s disease

Fistulas in Crohn’s disease are more difficult to treat. They are often hard to heal and have a tendency to recur. A surgeon in the setting of Crohn’s disease may be more likely to not perform a cutting operation and use a seton.

What are the results of surgery?

Most fistulae are simple and can be fixed with a single operation. About 10% however are complex and may require a more complex operation and even multiple operations to heal.

What are the risks of surgery?

The main risk of surgery is damage to the anal sphincter muscle. This muscle is a ring around the anus that closes the opening and prevents leakage. Care must be taken not to cut or damage too much of this muscle. If this were to happen control (continence) may be affected. This could be to flatus of potentially to faecal material. This is one of the reasons that a complex fistula where a lot of the muscle is involved may have a staged treatment with more than one operation.

What is an ano-vaginal fistula?

An ano-vaginal fistula is an abnormal connection between the anus and the lining of the vagina.

Why do they develop?

Ano-vaginal fistula can arise from many conditions. The most common is related to childbirth. With a vaginal delivery there can be a tear between the vagina and the anus. If this is unrecognised or the initial repair fails to heals a fistula can result. Other causes include anal abscess, surgical trauma, Crohn’s disease, radiation therapy, congenital and a malignant tumour.

How are they treated?

An operation will be required to close the openings in the vagina and the anus. If the anal sphincter muscle is also deficient then this will usually require repair as well. This operation is performed with a cut in the gap between the anus and the vagina.

What are the results of surgery?

The operation is about 90% successful. It is possible for the repair to break down.A second operation may be performed. This would be at a time when swelling and infection has resolved. A temporary stoma (bag) may be required to ensure better healing with any further attempted repair.

What are the risks of surgery?

The main problem with this operation is infection of the wound. This may require removal of the sutures and even drainage of the wound. The wound however will heal with time and leave a satisfactory scar.

What is a rectal prolapse?

A rectal prolapse occurs when either the inner lining of the rectum (mucosal rectal prolapse) or the whole of the rectum (full thickness rectal prolapse) passes through the anus, usually during the passage of bowel action.

What causes a rectal prolapse?

Rectal prolapse is a result of a weakened pelvic floor, usually as a result of childbirth. A floppy or redundant lower bowel often leads to the more severe types of rectal prolapse.

What symptoms are caused by a rectal prolapse?

If a large prolapse stays out for a prolonged period of time, it can become quite uncomfortable. It can also stretch the anal muscles, leading to a degree of incontinence. The lining of the prolapsed bowel often bleeds which can lead to concerns of bowel cancer.
If the prolapse is less severe, it can lead to symptoms of deep pelvic discomfort and the feeling that the bowel is not properly empty after going to the toilet.
A mucosal prolapse does not cause discomfort or pain. The most common symptom is of leaking of liquid faeces, often in the period immediately after going to the toilet. Patients with mucosal prolapse also often complain that they cannot clean themselves after the bowels have been opened, using copious quantities of toilet paper.

How is prolapse investigated?

If the prolapse is obvious, little further investigation is required. If there has been any rectal bleeding, it is important to have a colonscopy to rule out other causes for the bleeding, such as bowel cancer and polyps.
If the diagnosis is less clear, there are two options;

1. A special Xray can be performed, where the Xray doctor places Xray dye into the anus and then takes Xrays while this dye is passed into a commode.
2. The surgeon can examine for a prolapse under a general anaesthetic.

What is anal fissure?

An anal fissure is a tear in the lining of the anal canal. This is thought to be the result of minor trauma such as passing a hard bowel motion. Often this event is forgotten. The tear may heal on its own or persist as a chronic ulcer. Symptoms include anal pain with a bowel motion (and for some time afterwards) and the passage of blood (seen on the toilet paper). The diagnosis is made by inspecting the anus. Usually nothing needs to be inserted to see the fissure. In some people examination is difficult because of the pain and the diagnosis can only be made under an anaesthetic.

What are the treatment options?

• High fibre diet, pain relief
• Sphincterotomy
• Glyceryl Trinitrate paste (GTN)
• Botulinum toxin

What is a sphincterotomy?

This is an operation performed usually as a day case in hospital. A small cut is made to the anal sphincter muscle to relieve the spasm. This allows the fissure to heal. The results of this operation are excellent with high rates of healing.

What are the side effects?

In a small number of patients having sphincterotomy there can be minor soiling or loss of control. This is usually to flatus. This may be temporary but can be permanent.

How to use GTN paste.

GTN paste works by relaxing the anal sphincter muscle, thereby relieviing the spasm and allowing healing. The paste is applied to the anal skin 3 times per day. It does not need to be put up inside the anus. The amount is a small, enough to cover the tip of the finger. It is not uncommon to suffer the side effect of headache. If this occurs reduce the amount that is applied. It will heal up to 70% of fissures, but may take several weeks. The advantage of GTN is that no permanent damage is done to the anal sphincter muscle.

Botulinum toxin.

This is an experimental treatment for anal fissure. The toxin is injected into the anal sphincter muscle where it causes paralysis. This relieves the spasm of the muscle and allows the fissure to heal. The paralysis is temporary and lasts up to six weeks. No permanent damage occurs to the anal sphincter muscle.

What are haemorrhoids?

Haemorrhoids (piles) are part of normal anatomy. They are part of the normal lining of the anal canal. They occur in everybody. Haemorrhoids are only a problem if they cause symptoms. These are:

• Protruding lumps
• Itch, discomfort, pain
• Bleeding

What are the treatment options?

• Dietary
• Creams
• Injection
• Banding
• Haemorrhoidectomy

What is injection sclerotherapy?

The doctor injects the haemorrhoids in the anal canal with an oily irritant. This is performed as a procedure in the office or surgery. The needle is not felt as it goes in above the nerve fibres that feel pain. A burning discomfort however may be felt. Injection is suitable for small and medium sized haemorrhoids and will help most cases. Injection will not treat large haemorrhoids or extra skin at the anal canal.

What is banding?

This can be performed as an office procedure. A small rubber band is placed on the haemorrhoid. This causes it to strangulate and later drop off. There may be some discomfort at the time of the banding and it often feels as if there is a need to pass a bowel motion. This is because of the swollen haemorrhoid in the anal canal. Some blood will pass when the haemorrhoid drops off and this may be from three to seven days from the procedure. Complications may occur but are rare. If they occur contact your doctor. These include:

• Bleeding
• Severe pain
• Difficulty with passing urine

Rubber Band Ligation

The majority of haemorrhoids are treated with Rubber Band Ligation.

The treatment is especially appropriate for larger haemorrhoids and neither general nor local anaesthetic is required, as there are no nerve fibres in the lower bowel lining. Over 90% of haemorrhoids can be treated comfortably by this technique. Rubber bands are placed around the haemorrhoid to constrict the blood supply and cause the haemorrhoid to separate from its attachment to the bowel wall. The dead tissue separates over the next few days and, together with the rubber bands, is passed with the bowel motion. There is just a 10% chance of needing to repeat the procedure. Banding is often combined with injection of Phenol in almond oil at the same time to minimise the risk of bleeding following the procedure. This is carried out in the consultation clinic (or when sedated for another procedure such as colonoscopy, if indicated); there are no nerve fibres for pain sensation in the lower rectal lining (just above the normally sensitive anal skin, hence the ease of the technique in experienced hands when carried out in the clinic)

What is haemorrhoidectomy?

This is an operation for haemorrhoids. It may be done as a day procedure or you may stay overnight. It is chiefly indicated when the haemorrhoids are large or there are associated large skin tags that need removing.

Can haemorrhoids lead to cancer?

Haemorrhoids do not lead to cancer. Bleeding from the back passage however should not be attributed to haemorrhoids as a tumour (benign and malignant) can cause the same symptoms. Bleeding from the back passage should be appropriately investigated to determine the cause. If haemorrhoids are the cause then they can be treated.