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Fistula-in-ano (FIA)

This is a fairly common problem that arises around the anus. FIA is usually a troublesome problem for patients because it usually start as a pimple, that occasional burst, but doesn’t fully go away. Some have described it as volcano that remains dormant for a while, but may erupt from time to time. The postulated theory of how it originates, is usually from the blockage and infection of glands around the anus, or crytoglandular abscess. With this infection, there is a connection into the anal canal on one end, and the other end bursts open outside the skin around the anus. Hence, it starts off like a small pimple, which then erupts and bursts open to discharge either blood or yellowish pus. However, with the inner connection into the anal canal, the outer skin may heal but will recur after sometime and burst through periodically. Diagnosis is usually by clinical examination. FIA can be classified into low (or superficial) and high (or deep) .Treatment is dependent on how deep or high the fistula tract is. Antibiotics are usually not enough to treat a fistula and surgery is often needed.

What are the common symptoms of FIA?

  • Pain around the anus or a hard lump/ pimple
  • Discharge from this lump / opening
  • Bleeding from this lump
  • Infection and swelling etc.

However, we also need to differentiate from other conditions which may have similar symptoms, such as:

  • Anal fissure
  • Haemorrhoids
  • Hidradenitis suppuritiva
  • Pilonidal disease
  • Infection inclusion cysts
  • Cancer

How is it evaluated?

From the history and physical examination by a specialist, a lot of information can be gained. Sometime for recurrent or complex FIA, there might be an underlying problem that will need to be addressed first. Thereafter, further management options will be discussed, and these include:

  • Examination under anaesthesia(EUA)
  • Magnetic Resonance Imaging( MRI) of the anus
  • Endoanal Ultrasound (EUS)
  • Videoscope

How is FIA treated?

For simple, low FIA, surgery via fistulectomy or fistulotomy is usually sufficient. This is where the fistula tract is excised completely or laid open for it to heal. There will be a small open wound for it to heal from inside out. This is usually done as a day surgery procedure and requires no hospitalisation.

For complex or high FIA, there are several options available. If the FIA is high, it won’t be possible to do a simple fistulectomy as there would be too much tissue to cut through ( especially the anal sphincters) When surgery is being considered for a high or complex fistula, it is important to address draining the infection if any, eradicating the FIA tract but still preserving anal sphincter function. Hence, usual options include:

  • Seton insertion ( tight vs loose setons)
  • Advancement flaps
  • Fibrin glue, fistula plugs etc.

Newer minimally invasive, sphincter preserving methods:

  • Video- assisted anal fistula treatment ( VAAFT)
  • Ligation of intersphincteric fistula tract ( LIFT)

VAAFT is a minimally invasive technique done under general anaesthesia whereby a small scope is inserted into the FIA external opening, then the internal opening is located and closed with a surgical stapler or stiches, and the entire tract burnt and scrapped away. There are no extra cuts and patient can often return to work after a few days.

LIFT is useful for long, complex or recurrent FIA. Here, a small incision is made near the anus and the FIA tract divided and closed. The internal opening is also closed from the inside. Like the VAAFT, there is no cutting of any muscle, hence minimising any risk of damage to the sphincters. As in most operations for FIA, there is always a risk of recurrence, but with VAAFT and LIFT, the patient will unlikely end up any worse than before should this occur.

It is best to see your colorectal specialist to discuss the pros and cons of each method and which will be suitable for you.

Contact Information
38 Irrawaddy Rd,
#08-52 Mount Elizabeth Novena Specialist Centre
@ Mount Elizabeth Novena Hospital
Singapore 329563

Tel : +65 63347988
Fax : +65 63347966

Opening Hours:

Mondays - Fridays : 8:30 am - 5.30 pm
Saturdays : 8.30 am - 12.30 pm
Sundays & Public Holidays : Closed
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