Perianal fistula is the medical term for the formation of an abnormal channel/tunnel under the skin that connects the skin to the anus. Many patients complain why this perianal fistula is so difficult to heal. For more detailed information, see the following explanation of perianal fistulas.
What is a perianal fistula?
Anatomically this fistula is located around the anus so that it is said to be Peri or around the anus in male and female genitalia, including this can be involved in this perianal fistula if the opening of the fistula is located on it. Then Fistula itself by definition is an abnormal channel located in the human body. So this fistula can be in the stomach in the chest area or on the skin of the back abdomen etc., this does not include the Perianal Fistula which we discuss here.
Types of perianal fistulas
So by definition it is clear that there is an abnormal channel around the anus or perianal fistula. After we understand, we enter into the division of Perianal Fistula, namely:
The classification known as the PARK Classification includes;
- Extra sphincteric fistula starts in the rectum or sigmoid colon and continues downward, through the levator ani muscle and opens into the skin around the anus. Note that this type does not arise from the dentate line (where the anal glands are). This type of cause may be rectal, pelvic or supralevator in origin, usually from Crohn's disease or an inflammatory process such as an appendicular or diverticular abscess.
- The suprasphincteric fistula begins between the internal and external sphincter muscles, extends above and past the puborectalis muscle, continues downward between the puborectalis muscle and the levator ani, and opens an inch or so from the anus.
- The transsphincteric fistula begins between the internal and external sphincter muscles or behind the anus, crosses the external sphincter muscle and opens an inch or so from the anus. It may take a 'U' shape and form several external openings. This is sometimes called a 'horseshoe fistula'.
- The intersphincteric fistula starts between the internal and external sphincter muscles, passes through the internal sphincter muscles, and opens very close to the anus.
- The submucosal fistula passes superficially under the submucosa and does not pass through any of the sphincter muscles.
In general, there are fistulas that are shallow and deep, the deeper they enter the intestine, the more difficult and difficult it is to heal. So How do we know which perianal fistula is deep and shallow? Of course we can use Fistulography with contrast and regular X-rays, but this method is old-fashioned and old school so currently what is being used is MRI Fistulography, now if this is just a patent because the location of the anal fistula can be determined clearly and makes it easier for us to explain to the patient and the success of the operation to be carried out.
Perianal fistula symptoms
After we understand about the classification of fistulas and MRI fistulography, you must also understand the symptoms and forms of this Perianal Fistula so that you can immediately realize and go to the doctor as soon as possible. Symptoms of perianal fistula can be;
- Lumps like boils that burst and never dry
- Maceration of the skin due to fluid (skin redness)
- Pus, serous discharge and/or (rarely) fecal discharge - may be bloody or purulent
- Pruritus ani or itching in the anus
- Depending on the presence and severity of the infection: resulting in pain, swelling, fever, bad odor, thick secretions that make the area wet etc.
Then what should we watch out for? Most perianal fistulas originate from perianal abscesses or ulcers in the anus. Because it is considered trivial or because it is considered cured or because of an operation that is not clean enough, this perianal fistula thrives. As a result, it forms an opening in the skin around the anus which is always wet, smells and itches. These are the classic signs of a perianal fistula.
Treatment of perianal fistulas
The problem now is that if you have contracted fistula ani, is there no way out? Currently, there is a new tool from Germany in the form of a laser and its flexible fibers which are capable of finding difficult fistula cavities. The principle of this laser is to damage the epithelial wall of the fistula hole and shed it so that a new wound forms which can close spontaneously. This laser only damages the wall of the anal fistula, not the surrounding tissue, such as the anal muscles, nerves and blood vessels, so this laser is safe to use without worrying that the anal muscle is torn and can no longer function as is often the case in conventional torn perianal fistula surgeries. FiLAC also makes small wounds so that they heal faster than torn ones, as a result, treatment is easier, not terrible, and recovery is faster than conventional ones.
The only problem is that this tool is still used for one person, one fiber, so it's still quite expensive. This is done for fear of infectious diseases or even COVID 19 when using a tool that is repeated from one patient to another. But with the growing progress and popularity of Laser for the treatment of Perianal Fistula, it is hoped that it can overcome the problem of perianal fistula which is difficult to heal and treat complaints from their roots.
This article was written by dr. Tony Sukentro, Sp.B. (Surgeon Specialist at EMC Pulomas Hospital).