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What is an Anal Abscess or Fistula?

An anal abscess is an infected cavity filled with pus near the anus. It is commonly (90%) occur due to crypto-glandular infection.

Fistula in ano (Bhagandara) is a tubular ulcer connecting from inside the anal canal to outside perianal skin. It is the result of anal abscess.

Classification

There are majorly four types of Fistula in ano (Bhagandara) classifications based their anatomical relation and prognosis.

• 500BC- Susrutha classification
• 1934- Milligan & Morgan Classification
• 1976- Park's Classification
• 2000- MRI Classification

Acharya Susrutha is a father of surgery and also father of plastic surgery. He wrote Susrutha samhitha in 500BC. He classified Fistula in ano (Bhagandara) into five types, based their anatomical relation and prognosis. He is also given a specific surgical protocol for each variety of fistulas. It is an advanced protocol till date.

• Sathaponaka- Hidradenitis suppurativa
• Utragreeva- Intersphincteric fistula
• Parisravi- Complex Transphincteric fistula
• Sambhukavartha- High anal fistula
• Agantuja- Secondary fistula, involve vagina, urethra or due to injury

MRI classification- in 2000 St James's University Hospital (SJUH) classified fistula into five types based on three variables of sphincters, Anorectal ring and Spaces

• Grade 1: Simple Intersphincteric Fistula
• Grade 2: Complex Intersphincteric Fistula
• Grade 3: Simple Trans-sphincteric Fistula
• Grade 4: Complex Trans-sphincteric Fistula
• Grade 5: High Anal Fistula

Symptoms of Anal Abscess or Fistula

The common symptoms are the

• Pus discharge
• Pain
• Itching
• Swelling
• Fever

Patients with fistulas commonly have history of previous drained anal abscess and on and off recurrence.

Diagnostic studies

Most anal abscesses and fistula-in-ano are diagnosed and managed on the basis of clinical findings. Additional studies are needed for diagnosis of different grades of fistulas.

• Endo-anal ultrasound (TRUS)
• MRI Fistulogram

They have the accuracy up to 90% for mapping the tracts, cavities and internal opening of fistula to the specific targeted treatment protocol for better prognosis.

Treatment of anal fistula

Fistula is a purely a surgical disorder. Kshara sutra is a treatment of choice, which is a parasurgical procedure. In simple fistulas, a fistulotomy may be performed. But 95% complex fistulas are needed ksharasutra treatment preceded with deroofing of the cavity, partial fistulectomy, bifurcation of primary and secondary tracks, or IFTAK technique. The aim is to treat primary source of infection of fistula, to reduce period of treatment, to reduce recurrence rate and to restore anal continence.