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Perianal Fistula and Fistulotomy

Surgical Treatment of Anal Fistulas with Lay-Open or Sphincter-Preserving Techniques

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (5)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Genel Cerrahi department. Book Appointment →

What is Perianal Fistula and Fistulotomy?

Perianal fistula is an epithelialized tract connecting the anal canal (internal opening) to the perianal skin (external opening), with annual incidence approximately 9 per 100,000.

Pathophysiology: most commonly originates from cryptoglandular infection (90%) — bacterial infection of anal glands at the dentate line creates an abscess that drains through a fistula tract.

Parks classification (1976): intersphincteric (45%, between internal and external sphincters), transsphincteric (30%, through external sphincter), suprasphincteric (20%, above puborectalis), extrasphincteric (5%, bypasses sphincter complex).

Treatment goal is eradication of fistula with preservation of fecal continence; surgical decision depends on fistula type, sphincter involvement, and underlying pathology (Crohn's disease, malignancy, tuberculosis).

Symptoms

Persistent purulent or bloody discharge from external opening on perianal skin
Recurrent perianal abscess despite drainage
Pain and discomfort in perianal area, especially with sitting or defecation
Pruritus ani from chronic discharge
Visible external opening with surrounding inflammation, granulation tissue, or skin tag
Internal opening palpable on digital rectal examination at dentate line
Systemic symptoms (fever, malaise) during acute exacerbation with abscess formation
Multiple openings or complex tracts in Crohn's disease fistulas

Risk Factors

Adults aged 30–50 years, male predominance (male-to-female ratio approximately 2:1)
Prior perianal abscess (30–60% develop fistula after abscess drainage)
Inflammatory bowel disease, especially Crohn's disease (perianal manifestations in 25–30%)
Tuberculosis: tuberculous fistula common in endemic areas
HIV/AIDS and immunosuppression
Diabetes mellitus (impaired healing and recurrent infection)
Pelvic radiation, malignancy (rectal cancer, anal cancer), prior pelvic surgery
Obstetric injury (anovaginal or rectovaginal fistula in women after delivery or perineal surgery)

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Persistent perianal discharge or recurrent abscess
  • Painful perianal swelling requiring evaluation for abscess drainage
  • Known Crohn's disease with perianal symptoms (requires multidisciplinary approach with gastroenterologist)
  • Failed previous fistula surgery with persistent or recurrent disease
  • Symptoms of fecal incontinence after prior anal surgery
  • Unusual presentation suggesting underlying malignancy or systemic disease (suspicious mass, weight loss, systemic symptoms)

Treatment Methods

01
Initial evaluation: thorough history, perianal inspection, digital rectal examination, anoscopy/proctoscopy
02
Imaging: pelvic MRI is gold standard for complex fistulas (anatomic mapping, identification of secondary tracts, supralevator extension); endoanal ultrasonography with hydrogen peroxide enhancement is useful adjunct
03
Examination under anesthesia (EUA): direct visualization, probing of tract, identification of internal opening; often combined with surgical treatment
04
Goodsall's rule: external opening anterior to transverse anal line typically connects to internal opening directly; posterior opening connects to posterior midline by a curving tract
05
Acute abscess: incision and drainage as first step; primary fistulotomy at time of abscess drainage controversial (recurrence vs continence)
06
Seton placement: drainage seton (loose, e.g., vessel loop) for control of sepsis and tract maturation; cutting seton (slowly tightening) for gradual fistulotomy with continence preservation (less commonly used now)
07
Fistulotomy (laying open): gold standard for low intersphincteric and superficial transsphincteric fistulas; healing rates 90–95% with low risk of incontinence (5–15%)
08
LIFT procedure (Ligation of Intersphincteric Fistula Tract): identification and ligation of fistula in intersphincteric plane with division of tract; healing 60–80%, low incontinence risk; suitable for transsphincteric fistulas
09
Advancement flap (mucosal or full-thickness): excision of fistula and closure of internal opening with overlapping rectal flap; healing 60–80%; useful for high transsphincteric, suprasphincteric, and rectovaginal fistulas
10
Fibrin glue and fistula plug (collagen or biologic plug): minimally invasive sphincter-sparing options with healing 30–60%; less consistent results but no incontinence risk
11
VAAFT (video-assisted anal fistula treatment) and FiLaC (fistula laser closure): newer minimally invasive endoscopic and laser-based techniques with healing 60–80% and excellent continence preservation
12
Crohn's-related perianal fistulas: combination of medical (anti-TNF therapy) and surgical (drainage seton, advancement flap, LIFT); avoid aggressive surgery in active inflammation; multidisciplinary approach
13
Postoperative care: sitz baths, fiber-rich diet, stool softeners, avoidance of constipation, wound monitoring for healing
14
Long-term follow-up: clinical assessment at 4–6 weeks and 3–6 months for healing and continence; recurrence rate varies by technique and complexity

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.