Anal fistula symptoms: These complaints make you sit up and take notice
The anal fistula can become quite acutely noticeable with an anal abscess. After the surgeon opens the abscess, the pain subsides. Despite the best care, the wound does not heal completely and a small opening or a non-healing pimple remains? This is highly suspicious of an anal fistula! Also, if an abscess occurs repeatedly in the same place, anal fistula is the most likely cause.
Sometimes the symptoms also start insidiously: if there is dampness and itching, you might first think of haemorrhoids. Even after careful hygiene, the anus never stays clean for long; one discovers traces of blood or purulent secretion in the laundry. Sometimes a patient also notices the uncontrolled discharge of intestinal gases or traces of stool via the external fistula opening.
A fistula (lat. tube, pipe) describes a tubular duct, which is usually the result of a chronic, inflammatory process. The anal fistula in the true sense of the word has its origin in the anal canal and pierces variable parts of the sphincter muscle. Rarer forms of fistula originate from higher intestinal sections (rectal fistula) or are caused independently of the anal canal by impaled hair (sine pilonidalis) or systemic inflammation (acne inversa).
Anal fistula history: In prominent company
The oldest descriptions of anal fistulas date back to the 4th Pharaonic Dynasty in 2600 BC in Egypt. Sushruta in India around 600 BC and Hippocrates in Greece around 400 BC treated fistulas with textile drainages impregnated with extracts from medicinal plants. The surgical treatment of anal fistula goes back to the Frenchman Guy de Chauliac (1300 - 1368) and his British colleague John of Arderne (1307 - 1370).
Probably the most prominent fistula patient in history was Sun King Louis XIV. Charles Francois Felix freed him from his suffering by fistula splitting in 1686. The successful surgeon was elevated to the nobility and was henceforth allowed to call himself Felix de Tassy, furthermore he was granted land and the sum of 300,000 francs.
In 1835, Frederic Salmon opened the first specialist clinic for anal fistula in London. One of his best-known patients was author Charles Dickens, whose gratitude led to funding for the hospital extension from Lord Iveagh, a member of the Guinness Brewery dynasty. After the conversion, the hospital in City Road was named "St. Mark's Hospital for Fistula and other Diseases of the Rectum"(video Prof. Robin Philipps), today one of the most renowned colorectal departments in the world.
With Sir Alan Parks towards a modern understanding of anal fistula
Hippocrates still believed that a local trauma, for example while riding or rowing, would lead to a bruise which would then become festering. In the Middle Ages, knights were considered particularly at risk of developing anal fistula because they spent long periods in the saddle wearing heavy armour.
1878 discovered Chiari small glands in the wall of the anal canal (the proctodeal glands). He suspected that an infection of these glands could lead to anal fistula. Studies of Desfosses (1880) and Johnson (1914), who were able to demonstrate lymphatic tissue around the excretory ducts of the proctodeal glands.
Building on the work of Lockhart-Mummery (1929) and Eisenhammer (1958), he then founded the Parks then established the still recognised theory of the cryptoglandular origin of anal fistulas and the classification of these fistulas depending on their positional relationship to the sphincter muscle. He was able to prove that the intersphincteric glands located between the two concentric muscle rings of the internal and external sphincter are the cause of the vast majority of anal fistulas and have an excretory duct running through the internal sphincter. He identified tuberculosis, which was still more common at the time, and chronic inflammatory bowel diseases such as Crohn's disease as rare causes.
Pain, oozing, pus
A distinction is made between the complete anal fistula, in which a tunnel leads from an inner opening in the anal canal to the skin surface, and the incomplete fistula, in which the outer opening is missing.
Does an anal fistula always require surgery?
A sustainable cure of an anal fistula without surgery is not to be expected. Nevertheless, some therapeutic approaches can be of importance in individual cases:
Michael R.B. Keighley, Norman S. Williams (Eds.): Keighley & Williams' Surgery of the Anus, Rectum and Colon, Fourth Edition. CRC Press, 2018, ISBN 1351105027, Chapter 10, Anorectal Abscess and Fistula.
Chiari H. (1878): On the anal diverticula of the rectal mucosa and their relation to anal fistulas. Med Yearbooks 1878;8;419-27
Hermann G., Desfosses L. (1880): Sur la muqueuse de la region cloacale du rectum. Acad Sc 1880; 90:13017-2
Parks, A., & Morson, B. (1962). Fistula-in-Ano [Abridged]. Proceedings of the Royal Society of Medicine, 55(9), 751-758.