1) Disease Description (Causes and Symptoms)
- Definition and pathophysiology: An anal fistula is a condition in which inflammation that begins in the anal canal (anal glands) forms a tunnel (fistulous tract) toward the skin. Most begin as a perianal abscess (collection of pus) and develop into a fistula after the abscess has been drained.
- Clinical data: Even after incision and drainage of a perianal abscess, progression to a fistula has been reported in approximately 90% of cases. Fistulas confined internally (with no external opening) have been reported in approximately 16% of cases.
- Causes: Causes may include common bacterial infections (e.g., intestinal bacteria), inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis, tuberculosis, actinomycosis, sexually transmitted diseases, malignant tumors, pelvic infections, trauma, and radiation.
- Main symptoms: Continuous or intermittent discharge of pus/secretions (with a characteristic odor), pain or discomfort around the anus, swelling, fever (when accompanied by an abscess), and one or more external openings (in complex cases) may be observed. If the opening becomes blocked, pain, redness, and fever may worsen.
- Diagnostic tests: Diagnosis is possible through medical history-taking, visual examination, and digital rectal examination. When necessary, fistulography, endoanal ultrasound (endoanal US), and MRI are used to evaluate the shape and extent of the fistulous tract (simple vs. complex) and whether the surrounding sphincter muscles are involved.
2) Treatment Methods and Precautions
- Treatment goals: Eliminate infection (drain the abscess), prevent recurrence by removing the fistulous tract or closing the fistula opening, and preserve anal sphincter function (fecal control).
- Acute abscess (when there is pain, fever, or difficulty): Immediate incision and drainage. Antibiotics are used in combination for patients with signs of systemic infection, immunocompromised patients, and other high-risk groups such as people with diabetes.
- Definitive treatment (fistula):
- Simple and superficial (minimal sphincter involvement): Fistulotomy (lay-open) is the standard treatment and has a high treatment rate.
- For complex or high transsphincteric fistulas, or when sphincter preservation is necessary: Consider insertion of a seton (indwelling drain; either a loose seton or cutting seton), LIFT (ligation of intersphincteric fistula tract), rectal advancement flap, VAAFT (endoscopic method), or sphincter-preserving surgical methods such as sealants (fibrin glue) and plugs.
- Fistulas associated with Crohn’s disease: Remission is induced with antibiotics (metronidazole and ciprofloxacin) and immunomodulators/biologics (anti-TNF agents such as infliximab), followed by surgical treatment when necessary. Stem cell therapy has recently been used for some indications.
- Role of medication: Antibiotics play an adjunctive role (for systemic symptoms or special patient groups) and are unlikely to cure the fistula when used alone.
- Postoperative care: Sitz baths, wound care (maintaining cleanliness), prevention of constipation (fiber and laxatives), and painkillers. Observe for recurrence and drainage until the wound has healed.
- Precautions and complications:
- Recurrence (reformation of the fistula), fecal incontinence (especially when the sphincter is damaged), tissue damage due to chronic disease, and, rarely, possible malignant transformation if left untreated for a long time.
- Delayed early treatment may lead to increased complexity and a greater extent of surgery and complications.
- When to visit a hospital urgently: Severe pain, high fever, rapidly enlarging swelling (abscess), or systemic symptoms.
3) Outpatient Visit Checkpoints (Including Preparations, Records, and Example Questions)
- Items/materials to prepare and bring:
- A list of currently used medications (including antibiotics, anticoagulants, and immunosuppressants) and a record of allergies
- Previous test and surgical records (previous anal abscess/fistula surgery, colonoscopy, MRI, and ultrasound results)
- Medical history of chronic diseases (especially Crohn’s disease, tuberculosis, and diabetes)
- Photos of symptoms (if external drainage or an opening is visible, if possible), and records of the color, amount, and frequency of discharge
- Useful symptoms to record:
- When symptoms began and their course (intermittent/continuous), severity of pain, and whether fever is present
- Amount, odor, and color of discharge, changes in bowel habits, and whether antibiotics were recently taken
- Information to tell the doctor first during the outpatient visit (simple sentences):
- “Pus has been coming out frequently for the past few days.” (frequency of discharge)
- “I previously had surgery for an anal abscess.” (medical history)
- “I have Crohn’s disease (or another inflammatory bowel disease).” (underlying disease)
4) Examples of General Questions to Ask the Doctor
- Is this fistula simple or complex? (diagnostic significance)
- Do I need surgery? If so, what type of surgery do you recommend? (treatment choice)
- How high is the risk of impaired fecal control due to the surgery? (prognosis/complications)
- What is the expected recovery period before and after surgery, and when can I return to daily activities?
- Do I need antibiotics or other medications? What are the side effects?
- How likely is recurrence? What should I do to prevent it?
5) Examples of Disease-Specific Questions
- “Could you show me the shape of my fistula (internal location, number of external openings, and tract configuration) and explain whether it is simple or complex and the reasons for that classification?”
- “I have Crohn’s disease (or am undergoing immunosuppressive treatment). Is it better to manage this first with medication (biologics), or should surgical treatment take priority?”