Rectal fistula: symptoms and treatment of the disease. What is an anal fistula and what does it look like? Is treatment possible without surgery? Preparation for surgery to excise a postoperative fistula

A rectal fistula, or fistula in other words, is a pathological canal that arises in the subcutaneous tissue of the rectum and passes through the tissues surrounding it. Fistulas can be external or internal. An external fistula starts from the internal cavity and extends out into the lumen of the anal canal or onto the surface of the perineum, while the internal fistula connects the hollow organs inside the body.

In almost 90% of patients, the appearance of a fistula is provoked by the end. Often, a patient with symptoms of acute paraproctitis delays seeing a doctor. As a result, the abscess that forms in the subcutaneous tissue spontaneously opens, and its purulent contents come out.

The patient feels significant relief, his health improves, he believes that he is completely cured. But this is far from true. An inflamed anal crypt remains in the wall of the rectum, through which the infection enters the surrounding tissues and the inflammatory process continues. At the same time, the tissue begins to melt, and a fistula is formed that comes to the surface.

Fistulas form as long as the inflammatory process continues. Therefore, fistulas are often called chronic paraproctitis. In some cases, the cause of fistulas is a surgeon's mistake during the operation. This happens if the abscess is opened and drained, but radical surgery is not performed. Or during an operation to remove hemorrhoids, the surgeon, while suturing the mucosa, captures the muscle fibers, resulting in inflammation and subsequent infection.

Fistulas can form as a postoperative complication during surgical treatment of advanced and complicated hemorrhoids. Sometimes fistulas can be a consequence of birth injuries or occur after gross gynecological manipulations. In addition, their occurrence can be caused by:

• chlamydia
• Crohn's disease
• malignant tumors in the rectum
• syphilis
• intestinal tuberculosis
• diverticular bowel disease

Full. In this type of fistula, the entrance is located in the wall of the rectum, and the outlet is on the surface of the skin in the perineum or anal area. Sometimes in the rectal area several inlet openings may form at once, which then merge into one channel in the subcutaneous tissue and form one outlet opening on the skin. The main distinguishing feature of complete fistulas is that they extend outward to the surface of the body.

During a diagnostic examination, the doctor, using a special probe, can easily penetrate straight fistula tracts. If the channels are tortuous, this is almost impossible to do and the specialist cannot gain access to the internal opening. In this case, doctors assume that it is located in the place where the initial introduction of the infection occurred.

Incomplete. This form of rectal fistula does not have an outlet to the surface of the body, that is, these are internal fistulas. This type of fistula tract is rarely diagnosed and is considered by many doctors to be a temporary option for the development of a complete fistula. Incomplete fistulas may appear with the development of rectal, ischio-intestinal or submucosal paraproctitis. With such forms of paraproctitis, the abscess is often eliminated spontaneously or opened surgically.

Patients may not even realize that there is such a fistula inside their body; it is usually short and directed towards a purulent area. Sometimes the fistula opens as two internal holes. An experienced specialist may suspect its presence based on the characteristic complaints of patients. Patients complain of periodic pain in the lower abdomen, the appearance of pus in the stool and an unpleasant odor.
Based on how the internal opening is located on the wall of the rectum, fistulas are divided into lateral, posterior and anterior. By location, fistulas are classified depending on how the fistula canal is located in relation to the anal sphincter.

Transsphincteric fistula of the rectum is the most common, it is diagnosed in approximately half of the cases. It is noted that the fistula canal is located in any one area of ​​the sphincter (on the surface, deep inside or under the skin). In this case, the fistula canals can branch, the presence of ulcers is noted in the tissue, and cicatricial processes occur in the surrounding tissues. Such a fistula is usually located significantly above the anal sphincter, this is its peculiarity and explains its branched shape.

Intrasphincteric fistula of the rectum is considered the simplest of these pathological formations and is diagnosed in approximately 30% of cases. In another way, such fistulas can be called subcutaneous mucous or marginal fistulas. The main distinguishing characteristics of this type are: the recent duration of the inflammatory process, a direct fistula and the unexpressed nature of the scar manifestations. The external fistula opening is usually located in close proximity to the anus, and the internal opening can be located in any of the intestinal crypts.

Diagnosis of such fistulas is not particularly difficult; this can be done by palpating the perianal area. In these cases, the probe freely enters the external fistula opening and easily passes to the internal opening of the intestine.

Patients with this diagnosis often require additional examinations. These can be a wide variety of instrumental and clinical research methods. They will help to distinguish the chronic form of paraproctitis from other diseases that cause the formation of fistulas. In addition to the above types of fistulas, there is a classification that divides rectal fistulas into 4 degrees of complexity:

• 1st. The main feature is a direct fistulous tract, there are no scar changes in the area of ​​the internal opening, and there are no infiltrates or pus in the perirectal tissue.
• 2nd. There are no purulent pockets or infiltrates, but scars appear around the internal opening.
• 3rd. It is distinguished by a narrow opening of the entrance fistula canal, while there is no purulent content or infiltrates in the tissue.
• 4th. Abscesses and infiltrates appear in the perirectal tissue, and multiple scars are located around the wide inlet.

In this case, the localization of the fistula canal is not particularly important; the symptoms are the same for any location.

The patient becomes aware of an unpleasant complication when fistulous openings appear in the perianal area. From these wounds, pus and ichor are periodically released, which stain the underwear and force the patient to constantly use pads and frequently perform perineal hygiene. If the discharge becomes abundant, it causes redness and irritation of the skin, itching, and is accompanied by an unpleasant odor.

Straight fistulas that drain easily rarely cause severe pain. But incomplete internal fistulas can be very painful due to chronic inflammation. In this case, the pain may intensify when walking, coughing, or during bowel movements. When the fistula canal is blocked by a purulent mass or granulation tissue, an aggravation may occur, an abscess may form, the temperature rises, and signs of intoxication of the body may appear.

After opening the abscess, relief usually occurs, acute manifestations subside, but since healing of the fistula does not occur, the disease returns in relapses. During remission, the patient feels normal and, with careful hygiene, can lead a normal life. If the course of the disease is long and rectal fistulas constantly remind themselves of themselves with exacerbations, accompanying symptoms arise:

• Weakness, insomnia
• Decreased performance
• Periodic increase in temperature
• Sexual disorders

If complex fistulas exist for a long time, severe local changes are possible: deformation of the anal canal, sphincter insufficiency, scar changes in the sphincter muscles.

Diagnosis of the disease

At the initial stage, a patient survey is conducted, during which complaints characteristic of this pathology are identified. Diagnosing a fistula usually does not cause difficulties, since already upon examination the doctor detects one or several openings in the anal area, upon pressure on which purulent contents are released. With a digital examination, a specialist can detect the internal opening of the fistula.

In addition to the examination and history taking, the patient is prescribed tests: a biochemical blood test, a general blood and urine test, and a stool test for occult blood. This is done in order to confirm the diagnosis and exclude the presence of other diseases. In addition, a microbiological analysis of purulent discharge is carried out to determine the microbe causing suppuration. Cytological analysis of the discharge will determine whether these symptoms are a sign of cancer.

The decisive factor in diagnosing this disease is instrumental research methods:

All instrumental examination methods are carried out in the clinic and performed by experienced and qualified specialists. Before they are carried out, the patient is consulted and given recommendations on how to properly prepare for the examination.

These diagnostic methods will help exclude other diseases that can also cause holes in the anorectal area. These may be diseases such as tuberculosis, Crohn's disease, fiber cysts, osteomyelitis of the pelvic bones.

Sometimes, before surgery, a specialist may prescribe antibiotic therapy, painkillers and local healing agents to the patient. This is done to alleviate the condition; in most cases, conservative therapy is ineffective. Physiotherapeutic procedures may be prescribed during preparation for surgery.

This is done to reduce the risk of postoperative complications. Do not try to treat fistulas using traditional methods. Perhaps these remedies will help achieve temporary relief, but the main problem will not be solved, and time will be lost.

The main treatment method for direct canal fistulas is surgical. Removal of a rectal fistula is the only radical way to treat the pathology. Experts explain that surgical intervention during remission is not advisable, since during this period the fistula tracts are closed and there are no visible and clear landmarks. As a result, the surgeon may not completely remove the rectal fistula and thereby damage nearby healthy tissue.

The choice of surgical intervention technique will depend on the type of fistula, its location, the degree of scarring, the presence of abscesses or infiltrates in the perirectal tissues. The surgeon must competently perform excision of the rectal fistula, if necessary, open and drain purulent pockets, suturing the sphincter, and closing the internal opening of the fistula with a mucomuscular flap.

All necessary actions during the operation will be determined by the individual characteristics of the pathological process. Excision of a rectal fistula is performed in a hospital using general anesthesia. After the operation, the patient must remain in the hospital for at least a week under the supervision of a doctor.

Features of the postoperative period: diet

Usually, within a few hours after surgery, the patient is allowed to drink fluids. As you recover from anesthesia, discomfort and quite intense pain may occur. Therefore, during the first three days the patient is prescribed painkillers.

A bandage is applied to the site of the surgical wound, a gas outlet tube and a hemostatic sponge are inserted into the anus. They are removed one day after surgery during the first dressing. Dressings are quite painful; to facilitate the procedure, the patient is prescribed treatment with local anesthetics (ointments, gels). During this period, the doctor must carefully monitor the healing process; it is important that the edges of the wound do not stick together and that undrained pockets do not form in it.

If complex fistulas were removed, then a week after the operation a dressing will be required under anesthesia. During it, a deep revision of the wound is made and the ligature is tightened. To quickly heal the wound and reduce discomfort, the doctor may prescribe sitz baths with chamomile decoction or a weak solution of potassium permanganate.

In the first two days after the operation, the patient is prescribed a special liquid diet (kefir, water, a little boiled rice). This is done so that the patient does not have a bowel movement for several days after surgery. In the absence of stool, the postoperative wound will not become infected with feces, and the healing process will go faster.

In the postoperative period, it is important for the patient to follow a proper and balanced diet; meals should be divided, eating in small portions 5-6 times a day. Fatty, fried, spicy, pickled foods, smoked foods, spices, and carbonated water are excluded from the diet. You should give preference to foods high in fiber (vegetables, fruits), include porridge, grain bread, fermented milk products in your menu and drink more liquid.

This will help achieve soft stools and improve bowel function. and, if necessary, take laxatives.
After discharge from the hospital, the patient needs to be especially attentive to his own well-being and immediately consult a doctor if the following symptoms occur:

• Sudden rise in temperature
• Constant pain in the abdominal area
• Fecal incontinence, excess gas
• Painful bowel movements or urination
• The appearance of purulent or bloody discharge from the anus

These manifestations indicate the development of complications; it is necessary not to delay contacting a specialist and not to self-medicate. If there are no complications, the patient can return to normal life after two to three weeks. Complete recovery and wound healing occurs six weeks after surgery. When discharged from the hospital, be sure to discuss with your doctor when to come for a follow-up examination.

What complications may arise after removal of a rectal fistula? In some cases, bleeding may occur. In cases where the rectal fistula existed for a long time and periodically worsened, symptoms of intoxication and general poor health of the patient are noted. The constant inflammatory process contributed to the formation of scars in the tissues surrounding the fistula canal.

Scar changes occurred in the wall of the rectum, anal canal and around the sphincter. This can lead to the development of complications such as anal sphincter insufficiency and incontinence of feces and gases. In some cases, a relapse (return of the disease) may occur. The most serious and severe consequence of rectal fistulas may be their malignant degeneration.

In the prevention of rectal fistulas, timely elimination of the cause that causes them, that is, treatment of paraproctitis, plays an important role. In addition, it is necessary to exclude those factors that lead to traumatic damage to the rectum, treat it in a timely manner and prevent it from developing into an advanced form. Patients with rectal polyps and benign tumors should remember the need for surgical intervention.

Timely treatment will prevent the development of paraproctitis, reduce the risk of fistulas and will be a good preventive measure for the occurrence of various types of complications. If you experience unfavorable symptoms in the rectal area, seek medical help promptly, this will help you cope with the disease and avoid serious complications.

Often proctological diseases require radical measures; surgery to remove a rectal fistula is one of them and sometimes this is the only method to get rid of the disease. The fistulous tract is formed in the subcutaneous tissue of the rectum and is brought out, in most cases not far from the anus. Due to the fact that feces enter, the passages become inflamed and pus accumulates. You need to fight the disease when the first signs appear.

Surgery for rectal fistula is not always performed, but due to the threat to health and the ineffectiveness of other methods.

Types of fistulas

Classified:

• Full. Two or more exits, one of which is located in the anal lumen, and the second is brought out. There are several such moves, but they are all connected.
• Incomplete fistula. It does not have an open channel at both ends, it is a kind of bag in which pus accumulates, and it can be discharged both inside the intestines and outside in the anus.
• Internal fistulas. They open exclusively in the lumen of the rectum; there are also many of them.

Intestinal fistulas differ in their location; they can be localized on the side, behind and in front of the anus. They also differ in severity, which are presented in the table:

According to statistics, this disease is more common in women. In most cases, it occurs in the absence of treatment for paraproctitis or after removal of hemorrhoids, when the surgeon accidentally grabs muscle tissue when applying sutures. An infection attaches to the damaged muscle tissue, and a fistula develops with the formation of a purulent sac. Other causes of deviation:

• ruptures during childbirth;
• removal of an organ of the genitourinary system;
• chlamydia;
• Crohn's disease;
• oncology;
• infectious diseases;
• tuberculosis;
• constant constipation, diarrhea;
• intestinal hernia.

The symptoms of an anal fistula are pronounced. If it is caused by, then there will be a distinct pain in the anus, slight swelling and difficulty in defecating. Body temperature will rise and muscle weakness will occur. Such symptoms last from one to 2 weeks. Further, the fistula forms an outlet, and the pain subsides, and is replaced by unpleasant purulent discharge, which irritates the skin and smells unpleasant. If the disease appears for another reason, the patient may note:

• delayed excretion of urine and feces;
• bleeding, mucus and pus from the intestines;
• sensation of a foreign object.

Indications for surgery

Surgery for a rectal fistula will avoid complications and completely eliminate the problem.

It is worth noting that drug treatment and traditional medicine relieve discomfort for a short time. To eliminate the disease, excision of the rectal fistula is required. With the help of intervention, complete recovery can be achieved. In some cases, the process lasts for years, but with frequent suppuration or passage through the sphincter muscle tissue, it is necessary that the pathological passage be surgically removed.

There is no need to waste time on traditional medicine methods; rectal fistula does not resolve; healing is achieved through surgical excision.

Removal of a rectal fistula takes place under general anesthesia for complete muscle relaxation. The patient assumes a supine position with knees bent for full access to the anus. The choice of surgical intervention remains with the doctor and depends on the advanced stage of the disease and the patient’s condition. Types of surgical intervention:

• opening of the fistula;
• removal of the fistula over its entire area with or without further suturing;
• ligature method;
• laser burning of the fistula;
• filling the tunnel with various biomaterials.

Surgeries for rectal fistula can be performed using different methods, which differ in quality and recovery period.

Removal of the fistula along the entire cavity is carried out in intrasphincteric and transsphincteric cases. The passages are removed using the wedge-shaped method along with the fiber and dermis. If necessary, the sphincter muscles are sutured if the pus has eaten away the deep layers of the skin. If there are purulent bags, then they are all cleaned, a gas outlet tube is inserted into the intestines, and tampons with antiseptic agents are placed in the passage.

Extrasphincteric fistulas are removed using a ligature method. This is a complex operation, as it has many passages and purulent accumulations. The purpose of the intervention is the same: to clean and sutured the cavity. After removing the fistula canal, a silk thread is pulled and pulled outward, then tightened until it tightly wraps around the muscles of the anus. The postoperative period is long and painful.

Minimally invasive methods

They are applicable for simple fistulas: without branches and purulent accumulations. The laser burning procedure has become most popular. The operation is performed on an outpatient basis without unnecessary incisions and stitches. The rehabilitation course is much faster than with a radical method of therapy. The filling method is also popular. A special implant has been developed that fills the cavity and tightens it with healthy tissue. The procedure can heal the canal. Innovations are actively used in medicine, but have not been fully studied.

Rectal fistula (medical name - fistula) is a through tubular canal that connects the abdominal organs. The inside of the fistula is lined with epithelial cells or “young” connective fibers, formed as a result of the tightening and healing of various wounds and local tissue defects. About 70% of rectal fistulas form in the pararectal space and extend from the morganian crypts (pockets open to the movement of feces) to the skin. Anorectal fistulas go from the anus directly to the skin.

Treatment of rectal fistulas usually involves the use of surgical methods, as well as mechanical and chemical cleansing of the cavity. Very often, patients who have been diagnosed with purulent fistulas of the rectum are interested in whether the fistula can be cured without surgery. Experts agree that treating pathology with medications and folk methods is ineffective and can only be used as an auxiliary component to accelerate regenerative processes and quickly restore damaged tissue. There are also methods that allow excision of the fistula without surgical (invasive) intervention, so the patient must have full information about all available treatment methods.

Most proctological surgeons consider surgical treatment to be the most effective method of treating various fistulas, since during the operation the doctor can remove all damaged tissue, which significantly reduces the risk of relapse. Excision of fistulas using a scalpel is an invasive, highly traumatic operation that requires a long recovery period, so many patients are looking for ways to treat fistulas without surgery. They will be discussed below.

Laser treatment without surgery

This is one of the safest, most effective and least traumatic methods of treating fistula tracts, which has several advantages. Laser treatment, if indicated, can be carried out even in children and adolescents, although some doctors do not recommend using this technique in children under 10 years of age. The impact of laser beams does not cause discomfort or pain, and after the procedure there is no need for a rehabilitation period. After excision of the fistula with a laser, there are no scars or scars left on the skin, which is important if the operation is performed in the anorectal area.

Despite the large number of advantages, laser treatment also has significant disadvantages, including:

• high cost (in different clinics the cost can vary from 20,000 to 45,000 rubles);
• a fairly high probability of relapses and complications (about 11.2%);
• side effects in the form of anal itching and burning at the site of excision of the fistula;
• impossibility of use for purulent fistulas.

Note! Laser excision of fistula tracts is practiced in all private clinics in large cities, so there are usually no problems finding a laser proctologist surgeon.

Radio wave therapy

A more modern way to remove rectal fistulas is radio wave therapy. The method is suitable for the treatment of all types of fistulas, and its main advantage is the absence of the need to go to the hospital. The patient can go home 10-20 minutes after the procedure, since it does not require general anesthesia: the doctor performs all actions under local anesthesia (traditionally Lidocaine or Ultracaine is used).

Complete healing and tissue restoration after radio wave excision of a fistula occurs within 48 hours, so if the fistula was removed on Friday, the patient can go to work on Monday (the standard recovery period after surgery is at least 14 days). To determine the most suitable treatment method for himself, the patient can use the comparative characteristics given in the table below.

Table. Comparative characteristics of various methods of treatment of rectal fistulas.

Options	Laser treatment	Radio wave therapy	Surgical excision using a scalpel
Need for hospitalization	Usually not required (in some cases, the doctor may recommend observation for 1-2 days).	Not required. The patient can leave the clinic 20 minutes after the procedure.	The patient must be hospitalized in a hospital 2-3 days before the scheduled operation. After excision, the patient remains in the hospital for about 2-3 weeks.
Use of general anesthesia	Not required.	Not required.	Depending on the shape of the fistula and the extent of tissue damage, general anesthesia may be required.
Scars and scars after surgery	The probability is less than 5%.	The probability is less than 1%.	The probability is more than 92%.
Postoperative pain	None.	None.	They may bother you for several months, especially if the patient has a tendency to have stool disorders.
Healing and recovery period	From 2 to 5 days.	48 hours.	Three weeks.
Probability of relapses and complications	About 11.2%.	Practically absent.	Complications may occur.
Price	20-45 thousand rubles.	14,000 rubles.	It is carried out free of charge under the compulsory medical insurance policy.

Important! Despite all the advantages of non-invasive methods for treating perirectal fistulas (without a scalpel), the final decision on the possibility of using these methods should be made by the doctor, based on the degree and severity of the lesion and the general condition of the patient.

Treatment of rectal fistulas with traditional methods

When choosing the most appropriate treatment method, patients should understand that the only effective way to treat anorectal and pararectal fistulas is surgical therapy. Traditional methods can be used as an aid to relieve inflammation, draw out pus and ensure the outflow of exudate. Some components effectively eliminate pain and accelerate tissue healing, but complete recovery after using even the most effective recipes is impossible. This is due to the anatomical features of the structure of the fistula tracts, therefore the recipes given below are recommended to be used only as an auxiliary therapy after consultation with a doctor.

Honey ointment

Natural honey is one of the most effective anti-inflammatory remedies in traditional medicine. Honey and bee products (propolis, bee bread, royal jelly) contain more than 20 components that soothe the skin, relieve inflammation and stimulate tissue regeneration.

To prepare it, you need:

• Mix 5 tablespoons of liquid honey with two tablespoons of melted butter (use only natural butter made from pasteurized cow cream);
• add 15 drops of fir oil to the mixture;
• heat in a water bath until boiling and remove from heat;
• put in the refrigerator for 8 hours.

The resulting ointment must be lubricated with the affected area (you can use a tampon) 5-6 times a day. Treatment should be continued for 3-4 weeks.

Herbal ointment with lard

Recipes based on lard are used for fistulas accompanied by the formation of purulent exudate. A mixture of medicinal herbs disinfects the skin, prevents ascending infection of the rectum and soothes inflamed tissue, accelerating healing and tissue repair. To prepare the ointment you need:

• in a deep bowl, mix 1 teaspoon each of oak bark, chamomile and water pepper herb;
• add 300 ml of water and put on low heat for 20 minutes;
• Cool the broth and strain, then add 4 tablespoons of melted lard to it;
• mix everything and put it in the refrigerator to harden.

If the finished ointment is very liquid, you can add 1-2 tablespoons of butter, previously crushed using a fine grater, and then put the product back in the refrigerator. The ointment must be applied to a cotton swab and applied to the inflamed area. The tampon should be changed every 3-4 hours. A good therapeutic effect can be achieved after 2-3 weeks of daily use.

Lotions with aloe juice and plantain

Juice squeezed from aloe leaves has a pronounced bactericidal and anti-inflammatory effect. Such lotions draw pus from the wound, ensure its disinfection and reduce the intensity of pain. Plantain has a stimulating and regenerating effect, so herbalists advise adding this component to traditional aloe treatment.

To squeeze juice from aloe leaves, they must be thoroughly washed with cold water, crushed in your hands and cut along the side line, and then squeeze out the pulp. Plantain can be used as an infusion: pour 10 g of dried plantain root with a glass of boiling water and leave for 2 hours. All ingredients must be mixed and refrigerated for 1 hour.

A mixture of aloe juice and plantain infusion is used in the form of lotions: a cotton swab must be moistened generously with the product and applied to the end of the fistula tract. Lotions must be changed every 4 hours. Duration of use – 2 weeks.

Lotions with calendula

This is the easiest way to treat fistulas at home. All you need is an alcohol tincture of calendula (you can buy it at a pharmacy for 30-50 rubles) and cotton pads or swabs. The tampon must be moistened generously with the tincture and applied to the fistula for 20-30 minutes. You need to make 5-6 lotions per day. The duration of treatment depends on the tolerability of the components and the existing dynamics. The recommended course of therapy is 7-10 days.

Note! It is necessary to make lotions with alcohol tinctures after hygienic washing. At the beginning of treatment, the patient may feel a strong burning sensation caused by the effect of ethanol on the inflamed tissue. If such sensations do not go away within 30 minutes after removing the tampon, the skin should be rinsed generously with cool running water and lubricated with a soothing ointment, for example, Bepanthen.

Olive oil and vodka ointment

This ointment helps to quickly relieve inflammation and has a positive effect on the condition of damaged tissues, stimulating their regeneration. To ensure that the ointment has a thick consistency, you must purchase any fat base (glycerin, badger or goose fat, etc.) in advance. Mix 5 tablespoons of oil (it is better to use premium oil) with 50 ml of vodka and add 3 teaspoons of glycerin. If animal fat is used for cooking, the required thickness can be achieved using two tablespoons of fat.

All components should be thoroughly mixed and refrigerated for several hours. The ointment should be used up to 4-5 times a day; there is no need to wash it off after use. Significant improvements are usually observed already on the seventh day of treatment, but to achieve a stable result it is recommended to use the product for at least two weeks.

Rectal fistula is an unpleasant, painful pathology that can lead to serious complications if not treated on time. The only effective treatment for rectal fistulas today remains excision, which can be performed without surgery or the use of a scalpel. Home methods can be used as additional therapy, but they cannot replace full-fledged treatment.

Video - Excision of rectal fistula

A rectal fistula (rectal fistula, rectal fistula) is a pathological canal that forms in the perirectal tissue and connects the rectal cavity with other hollow pelvic organs or with the external environment.

Rectal fistulas occur as a result of purulent-inflammatory processes in the anorectal area, which are often complications of hemorrhoids. Therefore, timely treatment of hemorrhoidal disease can be considered a reliable method for preventing fistulas.

A rectal fistula not only brings a lot of inconvenience to the patient, but can also lead to the development of a malignant neoplasm.

Causes of formation of rectal fistulas

In almost all cases, the formation of rectal fistulas is caused by purulent inflammation of the perirectal fatty tissue, especially if the patient self-medicated and did not seek medical help from a specialist. The pararectal abscess eventually breaks into the pelvic cavity, and the canal through which the pus came out epithelializes, forming a fistula.

Rectal fistulas with paraproctitis can form until the inflammation in the perirectal tissue subsides. Therefore, rectal fistulas are often called chronic paraproctitis.

The second most common cause of the formation of rectal fistulas is, which is characterized by the formation of abscesses in the pelvic cavity and abdominal cavity. In some patients, a rectal fistula may be the first and only sign of Crohn's disease.

Also, rectal fistulas can be a complication of advanced hemorrhoids or postpartum trauma.

In rare cases, the cause of the formation of a rectal fistula may be the incorrect operating tactics of the surgeon, who prefers drainage of the perirectal abscess rather than its removal. In addition, iatrogenic fistulas can appear after the doctor hems the muscle layer while suturing the rectal mucosa. As a result of this, an inflammatory process develops, pathogenic flora attaches and a fistula is formed.

In addition to the above, the formation of rectal fistulas can be caused by the following diseases:

• chlamydia;
• tuberculous lesions of the anorectal region;
• syphilis.

Thus, rectal fistulas are almost always a consequence of other diseases, such as hemorrhoids, paraproctitis, Crohn's disease and others. Therefore, when the first signs of the mentioned diseases occur, it is necessary to immediately contact the appropriate specialist in order to prevent the formation of a rectal fistula.

Classification of rectal fistulas

In practice, the classification of rectal fistulas according to localization, etiology and anatomical characteristics is most often used.

Depending on the origin, rectal fistulas can be congenital or acquired. The latter, in turn, are divided into inflammatory, traumatic, tumor and symptomatic.

Depending on the location of the rectal fistula in relation to the anus, fistulas are distinguished as intrasphincteric, transsphincteric, extrasphincteric and horseshoe-shaped fistulas.

Rectal fistulas are also distinguished by the wall of the rectal canal on which their entrance opening is located. Therefore, anterior, lateral and posterior fistulas are distinguished.

Depending on whether the fistula opens somewhere or has a blind canal, incomplete and complete fistulas are distinguished.

Complete fistulas can be external or internal.

Characteristics of different types of fistulas

Intrasphincteric rectal fistulas are also called subcutaneous fistulas because they are located under the skin and open near the anus.

Transsphincteric rectal fistulas pass through the entire thickness of the circular muscle of the anus.

Extrasphincteric rectal fistulas bend around the orbicularis anus muscle and open above it.

Horseshoe rectal fistulas are the extension of fistulas from one buttock to the other.

A complete rectal fistula is a pathological canal that has an entrance and exit opening. Such fistulas connect the rectal cavity with the external environment, since the internal opening is located in the crypt of the rectal canal, and the exit opening is on the skin of the anorectal area.

An incomplete rectal fistula is a pathological canal that has only one opening - the entrance. An incomplete fistula is considered by some specialists as a stage in the formation of a complete fistula.

Incomplete rectal fistulas are difficult to detect. Their presence may be indicated by periodic pain in the lower abdomen, an admixture of pus in the stool and an unpleasant odor of stool.

Features of the course and symptoms of rectal fistulas

A reliable sign of a rectal fistula is the presence of a pathological hole in the perineum, in the anus or on the buttock, from which purulent contents are periodically released. The hole looks like a small wound, when pressed, pus or ichor is released.

The patient notices stains on his underwear or even clothes, which forces him to apply sanitary pads to the outlet of the fistula or regularly perform hygiene procedures. All this significantly affects the patient’s normal rhythm of life and disrupts his ability to work.

In addition, abundant purulent discharge from the fistula irritates the skin, causing burning and itching.

Another manifestation of a rectal fistula may be pain, which is more typical for tortuous and incomplete fistulas, in which chronic inflammation necessarily develops. The pain is nagging or aching in nature, and in some cases throbbing. Walking, sitting, coughing, intense laughter, and bowel movements can cause increased pain.

The most pronounced clinical picture is when the course of the fistula is blocked by thick pus or granulation, resulting in the formation of an abscess. In this case, the patient experiences a fever, general weakness, chills, increased sweating, pain in the joints and muscles, as well as other manifestations of intoxication of the body.

The condition improves only after unauthorized opening and drainage of the abscess. The patient feels normal, his general condition is not disturbed, he has only local manifestations of the fistula - discharge of pus from the fistula, maceration of the skin around the outlet, itching and burning. But healing of the fistula tract does not occur, so relapses of the abscess occur very often.

A long course of the disease with frequent relapses can lead to insomnia, impaired performance, depression, neurosis and even sexual dysfunction. In addition, fistulas can be a manifestation of life-threatening diseases, such as rectal cancer. Therefore, if you identify the above symptoms, we strongly recommend that you consult a coloproctologist for examination.

Rectal fistulas can have four degrees of severity, namely:

• first degree - characterized by the presence of a direct fistula without constrictions, pus and perirectal abscesses;
• second degree - indicates the appearance of scar tissue around the entrance opening of the fistula;
• third degree - manifested by a narrow fistula canal without suppuration and perirectal abscesses;
• fourth degree - characterized by a wide entrance hole with scarring, abscesses and infiltrates in the perirectal tissue.

When determining the severity of the disease, the location of the fistula is not taken into account.

Complications of rectal fistulas

With timely and proper treatment, rectal fistulas do not pose any danger to the patient’s health. But in the absence of timely and adequate treatment, as well as in the presence of aggravating factors, patients may experience the following complications:

• deformation of the rectal canal;
• deformation of perineal tissue;
• cicatricial changes in the circular muscle of the anus, resulting in possible fecal incontinence;
• cicatricial stricture of the rectal canal;
• suppuration of the fistula with the formation of an abscess;
• sepsis - the penetration of pathogenic microorganisms into the blood, in simple words - blood poisoning;
• malignancy of the fistula - the appearance of a malignant neoplasm at the site of the fistula is observed in cases where the fistula has existed for more than 5 years.

Diagnosis of rectal fistulas

The algorithm for examining a patient with suspected rectal fistula is as follows.

1. Subjective methods:

• collection of complaints;
• collection of anamnesis of illness and life.

2. Objective:

• inspection;
• palpation.

3. Laboratory diagnostics:

• general blood analysis;
• general urine analysis;
• blood chemistry;
• stool occult blood test;
• cytological examination of pus;
• inoculating pus on a nutrient medium and determining the sensitivity of the inoculated bacteria to antibacterial drugs, and others.

4. Instrumental diagnostics:

• fistula probing;
• irrigography;
• transvaginal ultrasound examination of the pelvic organs;
• fistulography;
• fibrocolonoscopy;
  CT scan;
• sphincterography.

When interviewing the patient, the specialist clarifies the complaints and also tries to find out what caused the rectal fistula.

During the examination, the doctor carefully examines the anorectal and perianal areas, buttocks and genitals to find all exit openings. When a fistula is identified, the doctor presses on it to determine the presence of contents - pus or ichor.

A digital examination of the rectum is required, during which the doctor can feel the internal opening of the fistula.

With a digital examination, a specialist can detect the internal opening of the fistula.

Laboratory blood tests are carried out to determine the severity of the inflammatory process (increased number of leukocytes, changes in the leukocyte formula, increase in erythrocyte sedimentation rate, appearance of C-reactive protein, etc.), as well as to exclude other diseases.

A cytological examination of the purulent contents of the fistula is performed to identify cancer cells. This is necessary to find the cause of fistula formation.

Be sure to carry out a bacteriological examination of the purulent contents, with the help of which you can identify the type of pathogen and select an antibacterial drug.

A fecal occult blood test is also no longer performed to diagnose the fistula itself, but to determine its cause (Crohn's disease, rectal cancer, colitis, etc.).

The most informative when diagnosing rectal fistulas are instrumental studies.

• Probing a rectal fistula is the insertion of a special probe into the external opening of the fistula canal to determine its direction, length and shape.
• Ultrasound examination of the pelvic organs using a vaginal probe can identify rectal fistulas, pararectal abscesses and infiltrates. The method is painless and safe.
• Fibercolonoscopy is carried out to examine the rectal mucosa, identify the internal openings of fistulas and collect material for histological and cytological examination.
• Fistulography involves X-ray visualization of rectal fistulas using contrast, which is injected with a syringe directly into the fistula canal.
• Sigmoidoscopy is used not only to identify rectal fistulas, but also to diagnose diseases that could cause the formation of fistulas.
• Computed tomography is rarely prescribed when complications of rectal fistulas are present, and other methods do not allow us to see the full picture of the disease.
• Sphincterometry is used to assess the functionality of the anal muscles.

Diagnosis of rectal fistulas is performed on an outpatient basis in a clinic. Before any instrumental examination, the specialist gives detailed recommendations on preparation for the procedure. After all, the result of the research largely depends on the quality of the patient’s preparation.

Treatment of rectal fistulas

Treatment of rectal fistulas should be entrusted exclusively to a specialist - a proctologist. Self-medication in this case will not always give the expected result and may even worsen the course of the disease.

The choice of treatment method for rectal fistulas is influenced by the cause of their occurrence, that is, the disease that led to the formation of fistulas, as well as the general condition of the patient.

The only effective treatment for rectal fistulas is surgery.

During the preoperative preparation and postoperative period, patients are prescribed diet, antibiotic therapy, anti-inflammatory, analgesic and healing agents, as well as physiotherapeutic methods.

Conservative therapy for rectal fistulas is prescribed to minimize the risk of complications after surgery, reduce inflammation, increase general and local resistance of the body and accelerate wound healing.

Antibiotic therapy for rectal fistulas

Antibacterial drugs for rectal fistulas are prescribed in the following cases:

• During the operation it was not possible to find an abscess;
• after surgery, body temperature remains high;
• inflammation of tissue in the area of ​​the postoperative wound;
• after fistulectomy;
• after plastic surgery of the anal muscles.

Patients are prescribed both systemic broad-spectrum antibacterial drugs and local medications (ointments, creams, suppositories), which include an antibiotic.

The following antibacterial drugs are highly effective for rectal fistulas:

• Metronidazole;
• and others.

Surgery to remove rectal fistula

Surgical treatment is carried out only during the period of exacerbation of the disease, since after the acute symptoms subside, the fistula canal closes and it is not always possible to find its boundaries. Therefore, the surgeon cannot completely remove the affected areas of tissue.

Surgery is performed only in a surgical hospital under general anesthesia.

There are several types of operations that are performed in the treatment of rectal fistulas. The most commonly used operations are:

• fistulotomy (opening of a fistula) into the rectal canal;
• fistulectomy (removal of fistula) into the rectal canal;
• fistulectomy into the rectal canal with opening and drainage of abscesses;
• fistulectomy into the rectal canal and suturing of the anal muscles;
• fistulectomy with plastic surgery of the rectal canal mucosa.

During the operation, the surgeon excises the fistula canal and the tissue around it that has scar changes. The postoperative wound is completely sutured and covered with a bandage, and if no complications arise in the postoperative period, then it heals completely within 1 week.

A gas outlet tube and a hemostatic sponge are inserted into the rectal canal and removed 24 hours after surgery. Dressings are carried out once a day using a local anesthetic, as the procedure is painful.

It happens that the operation is not limited to just excision of the fistula tract, since it is necessary to open and drain purulent pockets, perform sphincterotomy (partial dissection of the circular muscle of the anus) and perform plastic surgery of the internal opening of the fistula.

Therefore, the volume and tactics of the operation directly depend on the localization of the purulent process, the severity of the disease and the presence of complications.

Course of the postoperative period

The rehabilitation period after removal of a rectal fistula takes from 3 to 6 weeks.

At this time, all means are aimed at eliminating pain, normalizing stool, accelerating the healing of postoperative wounds and preventing complications. For this purpose, patients are prescribed a special liquid diet, painkillers and healing agents, antibacterial and, if necessary, laxatives.

24 hours after surgery, the gas outlet tube and hemostatic sponge are removed from the rectal canal. The manipulation is carried out under local anesthesia, as this procedure is quite painful.

Dressings are carried out once a day for 2-3 weeks. The postoperative wound is washed with an antiseptic (hydrogen peroxide, Chlorhexidine), a healing and/or antibacterial ointment is applied, and then a sterile gauze bandage is applied.

In the case of an extensive operation for complex fistula tracts, after about 5-7 days, dressing is performed with a deep revision of the wound and tightening of the ligatures. The procedure is also performed under anesthesia.

The patient's stay in the hospital takes from 7 to 10 days. After discharge from the department, you will need to come for an examination by the surgeon who performed the operation. The doctor will set a date for the re-examination.

In the postoperative period, you need to carefully monitor your well-being and if you experience any unpleasant sensations in the problem area, you should contact your attending proctologist.

The following symptoms may indicate the development of complications:

• sudden increase in body temperature;
• pain in the lower abdomen and anus;
• flatulence;
• leakage of feces or pus from the rectal canal;
• bleeding from the anus;
• pain during bowel movements;
• pain during urination;
• an admixture of blood or pus in the stool.

Complications after surgical treatment of rectal fistula

In the later stages of the postoperative period, insufficiency of the orbicularis anus muscle and re-formation of a rectal fistula may develop.

Diet after removal of rectal fistulas

All patients are prescribed a liquid diet for 2-3 days after surgery. This measure is necessary so that the patient begins to recover only 2-3 days after the operation, since bowel movement at an earlier date can cause severe pain, bleeding or infection of the postoperative wound.

Patients are allowed to drink kefir, water, fermented baked milk, low-fat yogurt, and also eat a small amount of white boiled rice.

After 2-3 days, the diet is gradually expanded by introducing other products into the menu. Nutrition in the postoperative period should be balanced and healthy. It is recommended to eat food 5-6 times a day in small portions.

The patient's menu should consist of cereals, soups, lean meats, fish and poultry, fermented milk products, vegetable salads, fruits, and grain bread.

If you are prone to constipation, vegetable salads, beets, zucchini, carrots, prunes, dried apricots, plums, and baked apples will help.

Brief overview of drugs for the treatment of rectal fistulas

Metronidazole

Metronidazole belongs to the antimicrobial drugs that are active against anaerobic pathogenic microorganisms and protozoa.

Method of administration and dosage: for rectal fistulas, the drug can be used intravenously, intramuscularly and orally. Metronidazole is prescribed at a dose of 7.5 mg/kg. The daily dose of the drug is divided into three doses, the interval between which should be 6 hours.

Metronidazole is often combined with Amoxicillin, since this combination can destroy both anaerobic and aerobic pathogenic microorganisms.

Side effects : allergic reactions, nausea, vomiting, diarrhea or constipation, abdominal pain, dry mouth, headache, dizziness, sleep disturbance and others.

Contraindications : severe liver failure, intolerance to drug components, organic diseases of the central nervous system, breastfeeding, first trimester of pregnancy.

Price:

• Metronidazole tablets 500 mg – 75 rubles per pack (20 tablets);
• powder for preparing injection solution Metrogyl 500 mg, 100 ml - 30 rubles per 1 bottle.

Neomycin sulfate

Neomycin sulfate is a broad-spectrum antibacterial drug, to which both aerobic and anaerobic bacteria are sensitive.

Method of administration and dosage: the drug can be taken orally, administered intramuscularly or intravenously. A single dose of the drug is 100-200 mg, and a daily dose is 400 mg.

Side effects: nausea, vomiting, diarrhea, allergic reactions, hearing loss, kidney dysfunction, candidiasis.

Contraindications: severe kidney disease, acoustic neuritis, breastfeeding.

Levomekol ointment

Levomekol ointment is a multicomponent drug, which includes the antibiotic chloramphenicol and the reparative methyluracil. The drug effectively eliminates inflammation, destroys pathogenic microorganisms, prevents bacterial complications and accelerates tissue repair.

Method of administration and dosage: 1 gram of the drug is applied to the postoperative wound during dressing 1-2 times a day.

Side effects: local manifestations of allergies (itching, swelling, hyperemia, urticarial rash).

Cost: 125 rubles per tube (40 grams).

Levosin ointment

Levosin ointment is also a multicomponent drug with antimicrobial, healing, anti-inflammatory and analgesic pharmacological properties.

The drug contains methyluracil, chloramphenicol, trimecaine and sulfadimethoxine.

Directions for use and doses : A piece of gauze is soaked in 1 gram of the drug, which is placed on the postoperative wound and covered with a bandage. The procedure is carried out 1-2 times a day.

Side effects: local manifestations of allergies (itching, redness of the skin, swelling, urticaria).

Contraindications : individual intolerance to the components of the drug.

Price : 85 rubles per tube (40 grams).

Rectal suppositories Proctosedyl M

Rectal suppositories Proctosedil M consists of hydrocortisone, butamben, framycetin, benzocaine and esculoside.

Thanks to such a rich composition, the drug has pronounced anti-inflammatory, antimicrobial, analgesic, antipruritic and angioprotective effects.

Directions for use and doses : 1 suppository is inserted into the rectal canal twice a day after bowel movements and hygienic toilet of the anus. The course of treatment is no longer than 1 week.

Side effects: dryness of the rectal mucosa, local manifestations of allergies (itching, swelling, hyperemia and dermatitis of the anus)

Contraindications : individual intolerance to the components of the drug, pregnancy, breastfeeding, age under 3 years, damage to the anorectal area by viral, fungal or tuberculosis infections.

Cost: 430 rubles per package (20 capsules).

Rectal suppositories Olestezin

This is a combination drug that consists of two active ingredients - sea buckthorn oil and anesthesin.

The drug effectively eliminates the inflammatory process, instantly relieves pain and accelerates healing.

Directions for use and dosage: 1 suppository 2-3 times a day is inserted into the anus after bowel movements and hygienic toileting of the anorectal area. The course of treatment lasts from 5 to 10 days.

Side effects: allergic reactions in the form of itching, redness, swelling and dermatitis of the anorectal area.

Contraindications: individual intolerance to the components of the drug.

Cost: 150 rubles per package (10 candles).

Traditional methods of treating rectal fistulas

Folk remedies and methods for rectal fistulas can be used exclusively as additional therapy, since their effectiveness is not enough to eliminate the problem. We strongly recommend using traditional methods of treatment for rectal fistulas only after consultation with your doctor.

• Sea salt baths : 20 grams of sea salt and soda are dissolved in 6 liters of hot boiled water. When the solution has cooled to body temperature, it is poured into a wide basin, into which they sit so that the water covers the anus. Baths are carried out for 10-15 minutes before bedtime for 10-14 days. Sea salt and soda will help reduce inflammation in the postoperative wound area and speed up healing.
• Baths with a decoction of oak bark, St. John's wort and calendula: 3 tablespoons of each of these ingredients are poured into two glasses of boiling water, put on low heat and boil for 10 minutes. After which the broth is filtered, diluted in 5 liters of hot boiled water and cooled to body temperature. The procedure is carried out for 10-15 minutes once a day. The course of treatment is 1-2 weeks.
• Microclysters with infusions of chamomile, sage and yarrow: 1 teaspoon of these ingredients is poured into 4 cups of boiling water, covered and left for 20-30 minutes. When the infusion has cooled to body temperature, it is taken into a syringe (40-60 ml) and injected into the rectal canal. Before a therapeutic microenema, it is necessary to perform a cleansing enema. The procedure is carried out once a day before bedtime for 10 days. Watering microenemas perfectly eliminate inflammation and restore tissue.
• Microenemas with potato juice: 15 ml of freshly squeezed potato juice is heated to body temperature and injected into the anus using a syringe without a needle once a day at night. Before the microenema, a cleansing enema should be performed. The course of treatment is 10 days.
• Rectal inserts: a gauze swab is soaked in badger fat and inserted into the anus once a day at night. In the morning, the insert will come out naturally during bowel movements. The course of treatment is 7-10 days.

Rectal fistula

Timely treatment of hemorrhoids and other diseases of the intestines and anorectal area will prevent the development of purulent inflammation of the perirectal fatty tissue, and this, in turn, will eliminate the risk of rectal fistulas.

Therefore, if you experience discomfort, itching and pain in the anus, discharge of blood or pus during defecation, prolonged constipation, or if you identify an external opening of the fistula canal on the skin of the perianal area, you should immediately contact a proctologist at the nearest clinic. Only a specialist can make an accurate diagnosis, carry out effective treatment and prevent the development of complications.

If you experience unfavorable symptoms in the rectal area, seek medical help promptly, this will help you cope with the disease and avoid serious complications.

The appearance of a rectal fistula - a pathological communication between the intestinal lumen and surrounding tissues - in 95% of cases is a complication of poorly treated, accompanied by inflammation of the fiber located around the intestine. This formation exists for at least several months and occurs with phases of exacerbation and remission, when the compaction that appears due to inflammation decreases in size.

In this article you can learn about the causes, types, methods of diagnosis, treatment and prevention of rectal fistula. This information will help you understand the essence of this proctological disease, and you will be able to ask your doctor any questions you may have.

Rectal fistula is a chronic disease. Its initial stage occurs in the form of acute inflammation of the perirectal tissue, accompanied by the melting of surrounding tissues and the release of pus. Subsequently, this focus breaks into the intestinal cavity, the walls of the pathological communication become denser (i.e., a fistula is formed) and pus begins to be released through the rectum to the outside.

This proctological disease provokes many unpleasant symptoms in the patient, which affect the general health due to the development of general intoxication of the body. In the absence of timely treatment, a fistula can lead to destruction of the anal sphincter and fecal incontinence. A more dangerous complication of this disease can become.

Causes

In 8 out of 10 cases, the cause of rectal fistula is paraproctitis.

In most cases, a rectal fistula is formed due to purulent inflammation of the perirectal tissue, and its appearance indicates an already present acute or chronic paraproctitis. The reasons for the formation of a fistula are as follows:

• failure to consult a doctor in a timely manner if paraproctitis develops;
• incorrectly prescribed treatment;
• improper performance of an operation to remove an abscess, accompanied only by opening and draining the abscess without prescribing correctly selected antibiotic therapy.

Paraproctitis itself is most often provoked by mixed flora:

• coli;
• staphylococci;
• streptococci.

In more rare cases, purulent inflammation is caused by specific infectious agents such as pathogens, actinomycosis or clostridia.

The state of immunity is also of no small importance in creating the prerequisites for the occurrence of paraproctitis and fistula. In many patients, acute or chronic paraproctitis occurs without the formation of a fistula in the rectum, but when there is a malfunction in the immune system, they form. The following conditions can cause such violations of the human body’s defense system:

• specific infectious diseases;
• bowel problems: frequent constipation or diarrhea;
• acute and chronic intestinal infections;
• a history of intestinal diseases: enteritis, anal fissures, papillitis, cryptitis, etc.

Varieties

Any rectal fistula consists of an external and internal opening (or damaged anal crypt) and a fistulous tract. In essence, such a formation is a tube with two hollow ends (its shape can be different). The external opening of the fistula is formed in different places: in the intestine, in the vagina, on the skin around the anus or buttocks.

Depending on the number of holes, a rectal fistula can be:

• complete - has two openings located on the skin and anal crypt (i.e., the rectum communicates with the external environment);
• incomplete - such a fistula differs from a complete one in that it has only an external opening on the rectal mucosa, and the internal passage ends blindly in the thickness of the perirectal tissue (a number of experts are inclined to believe that an incomplete fistula is only an intermediate stage to the formation of a complete fistula);
• internal - both openings of the fistula open in the rectum.

Depending on the location of the internal fistula opening on the surface of the rectal wall, experts divide incomplete fistulas into:

• front;
• lateral;
• rear

Depending on the location relative to the anal sphincter, all rectal fistulas are divided into:

1. Intrasphincteric (or subcutaneous mucosal marginal). The internal opening of such fistulas is localized on the intestinal crypt, and the external opening is located near the anus. The course of such fistulas has a straight shape.
2. Transsphincteral. The fistulous tracts of such formations contain purulent pockets, branches in the perirectal tissue and scar changes caused by purulent fusion of tissue. The channels of such fistulas pass through the superficial, subcutaneous or deep portion of the sphincter.
3. Extrasphincteral. Such rectal fistulas open in the area of ​​the crypts, and their course goes around the external sphincter. The course of the fistulas has a tortuous shape and contains purulent pockets and scars. In some cases, such fistulas have a horseshoe shape and not two, but several holes.

Depending on the degree of complexity of the structure, extrasphincteral fistulas of the rectum are:

• I – do not contain purulent pockets and scars, have a relatively straight lumen and a small internal opening;
• II – there are scars on the internal hole;
• III – there are no scars on the internal opening, but purulent inflammation is present in the tissue tissues;
• IV – the internal opening of the fistula is widened, has scars, inflammatory infiltrates and purulent pockets in the surrounding tissue.

Depending on the time of formation, rectal fistulas can be:

• congenital;
• acquired.

Symptoms

The manifestations of a rectal fistula depend on the location of the fistula with purulent contents and the state of the immune system, which will determine the severity of the manifestations of such a pathological formation.

After suffering paraproctitis in a patient:

• there is pain in the anus;
• a hole appears from which pus is released (traces of it will be visible on underwear and/or clothes).

Sometimes, along with purulent discharge, ichor remains on the tissue, appearing due to damage to the blood vessels. If the fistula does not have an external outlet, then the patient experiences only pain and/or discharge from the lumen of the rectum or vagina.

The appearance of moisture and pus in the groin area leads to weeping of the skin and its inflammation. Due to such changes, the patient complains of the following symptoms:

• unpleasant odor;
• skin redness;
• rashes (sometimes);
• burning and itching sensations in the groin area.

After opening the fistula, the pain becomes less pronounced. The pain syndrome is more intense in those moments when a person defecates, sits, walks, suddenly gets up from a chair, or coughs. When urinating, the patient experiences a stronger burning sensation in the skin of the groin, since the substances in the urine cause even more severe irritation of the damaged skin.

When a fistula is opened into the vaginal lumen, women often develop inflammatory diseases of the urinary and reproductive systems:

• endometritis.

In the absence of timely treatment, higher anatomically located organs may also be affected: ureters, kidneys, fallopian tubes and ovaries.

In men, a rectal fistula can affect the nerves and genitals. In such cases, in addition to the development of inflammatory diseases of these structures, the patient develops signs of impaired potency.

After an exacerbation, the symptoms of rectal fistula become almost hidden or the manifestations of the disease completely disappear for a certain period of time. Relapses occur due to blockage of the fistula lumen with necrotic masses or granulations. This development of the disease can cause the formation of an abscess, which can subsequently open on its own. After draining the purulent focus, its symptoms are completely eliminated - the pain becomes barely noticeable, and the amount of purulent discharge is significantly reduced. However, after the resulting cavity has completely healed, the symptoms reappear after some time.

Against the background of accumulation of pus, the patient develops signs of general intoxication:

• fever (up to 40 °C);
• weakness;
• excessive irritability;
• sleep disorders;
• loss of appetite, etc.

During remission, the patient’s general well-being does not change, and if he is able to carefully observe the rules of personal hygiene, then exacerbations do not occur for significant periods of time. However, this fact should not lead to postponing a visit to the doctor until later, since any chronic disease can lead to various negative consequences.

Possible complications

Over a long period of time, rectal fistula can cause:

• Deformation of the anal sphincter and changes in the condition of the muscles surrounding this anatomical area. As a result, the patient develops rectal sphincter insufficiency.
• In some cases, inflammatory and necrotic processes occurring in the pararectal area cause the proliferation of connective tissue (i.e., scarring) and narrowing of the anal canal.
• The most severe complication of rectal fistula can be a cancerous tumor of this part of the intestine.

Diagnostics

A rectal fistula is diagnosed by a proctologist by collecting complaints, life history and disease data, examining and palpating the area around the rectum.

The diagnostic plan carried out to identify a rectal fistula, in addition to examination and questioning of a doctor, includes various types of instrumental studies.

After interviewing the patient and clarifying some details of his complaints, the proctologist examines the patient in a special chair. During the examination, the doctor pays attention to the following points:

1. Identification of the external opening in a complete fistula. When it is detected, pressure is applied to the area around the open fistula tract with the fingers. In such cases, exudate of a mucous or purulent nature is released from the hole.
2. Identification of two external fistula tracts. When examining the groin area, the doctor may find two holes in the skin from which secretions are released. In such cases, a presumptive diagnosis of “horseshoe-shaped rectal fistula” is made.
3. Identification of multiple external fistula openings. If more than 2 fistula tracts are detected in the groin area, the doctor can draw conclusions that the disease was caused by specific infections and prescribe additional studies to identify them and further therapy.

The nature of discharge from a fistula is often purulent. They are usually yellow in color and do not have a distinct fetid odor.

If the formation of a rectal fistula is caused by the causative agent of tuberculosis, then the discharge from the fistula has a liquid consistency, and with actinomycosis it is crumbly and scanty. The appearance of bloody or bloody discharge may indicate damage to a blood vessel or the development of a cancerous tumor. In such cases, the patient is prescribed additional studies to confirm or refute the process of malignancy of the fistula.

With incomplete rectal fistulas, the patient has only an internal fistula tract, and it can only be detected during a proctological examination. To do this, the doctor may perform a digital examination.

To assess the structure of the fistula, it is probed using a special surgical instrument. Such a study allows us to determine:

• shape;
• length;
• location of the fistula tract in relation to the anus;
• the presence of scar changes and/or purulent pockets.

To identify the location of the external fistula tract, in some clinical cases anoscopy and tests using dyes (for example, methylene blue) are performed. Even if such diagnostic procedures do not provide the desired data on the clinical picture, then fistulography is performed to detect the fistulous tract. This X-ray examination is carried out using dyes (for example, a water-soluble or oil-based iodine compound).

In addition to the diagnostic methods described above, the patient is prescribed sigmoidoscopy. With the help of such a study, the doctor can:

• assess the condition of the rectal mucosa;
• identify signs of inflammation;
• detect neoplasms.

Sometimes, to exclude other diseases of the rectum, the patient is prescribed irrigoscopy with the introduction of a barium suspension into the intestinal lumen.

In complex clinical cases, sphincterometry is performed to assess the condition of the sphincter, which may be affected by inflammatory and purulent processes. If necessary, ultrasonography or CT is recommended for a patient with a rectal fistula.

To assess the severity of the patient's general health, the following laboratory tests are performed:

To exclude erroneous diagnoses, patients are subject to differential diagnosis with the following diseases:

• epithelial coccygeal duct;
• adirectal tissue cyst;
• rectal cancer;
• osteomyelitis of the pelvic bones.

Treatment

Therapeutic measures in the fight against rectal fistula in the vast majority of cases are ineffective and only lead to chronicity of the inflammatory-purulent process, causing the formation of a fistula. That is why the treatment of such a disease should only be radical, that is, surgical.

After the onset of remission, performing a surgical operation is irrational, since at this stage the doctor will not see clear guidelines along which it is necessary to excise tissue.

• Planned interventions can be performed when an abscess appears - an abscess of the rectum. To do this, the surgeon opens it and drains it.
• Next, the patient is prescribed massive antibiotic therapy aimed at eliminating the causative agent of the disease. The choice of drugs depends on the cause of the formation of the fistula, and antibiotics are administered not only orally and parenterally, but also in the form of solutions for washing the drainage system created during the operation.
• To accelerate the onset of the required therapeutic effect and in the absence of contraindications, the patient is prescribed physiotherapy (Ultraviral irradiation and electrophoresis).

After eliminating all acute inflammatory processes, the patient undergoes the following operation. To remove a fistula, various types of surgical interventions can be performed, aimed at dissection or complete excision of the tissues of the fistula tract. If necessary, during the operation the doctor may perform:

• sphincter suturing;
• drainage of purulent pockets;
• displacement of the muscular-mucosal or mucous tissue flap to completely close the formed internal course of the rectal fistula.

The choice of intervention method depends on the clinical case. Often, the full extent of the operation becomes known after it has begun, that is, after the surgeon can visually assess the location of the fistula, the presence of compactions and purulent leaks, and the severity of scar lesions in the pararectal area.

After surgery, the patient must follow all the doctor’s recommendations:

• take prescribed medications and laxatives;
• limit physical activity and expand it only after consulting a doctor;
• adhere to a special diet to prevent constipation, which aggravates the postoperative period and interferes with the healing of the postoperative wound surface.

Complete tissue healing after removal of the fistula occurs in approximately 20-30 days, and with deep-lying fistulas or fistulas with a complicated course, this period can increase significantly.

Possible complications after surgical removal of a rectal fistula may include:

• anal sphincter insufficiency;
• recurrence of rectal fistula.

The likelihood of their occurrence largely depends on the correct choice and implementation of a particular method of surgical intervention, compliance with the doctor’s recommendations in the postoperative period and the surgeon’s skill level.

Forecast

The prognosis for rectal fistula depends on the severity of the disease.