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Rectal abscess and anal fistula are rare diseases in this area. Among all proctological diseases, they constitute only about 5-8 percent of the reasons for using the help of specialists. What are the causes and symptoms of perianal abscess and what are anal fistulas? What is the treatment?

Perianal abscessandanal fistulaare two phases of the same disease - the abscess is the acute phase, and when it breaks through the skin develops a fistula. A perianal abscess is an enclosed space containing pus and bacteria located in the soft tissues near the anus and rectum. It occurs mainly in the 3rd and 4th decade of life, more often in men than in women (2-3: 1). When the abscess spontaneously breaks through the skin, an anal fistula develops. The area of ​​the inflamed anal gland in the anal canal is most often the site of the internal opening of the fistula, and the site of the opening of the fistula on the skin is the external opening. The fistula channel passes through the sphincter muscles at different heights and therefore the fistula almost always weakens the sphincters. The fistula canal usually runs in the place where there was an abscess, and for this reason the external opening is often located in the scar after the abscess incision.

Perianal abscess and anal fistula: pathogenesis

Anal urethral glands (4-10) are found in Morgagni's sinuses, at the level of the dentate line. They extend deep into the submucosa, pierce the internal anal sphincter and reach the intersphincteric space.

The location of the abscess depends on the starting point of infection and the direction of its spread along anatomical spaces.

The primary function of these glands is to moisturize the anal canal. If their lumen is blocked, there is always an accumulation of non-venting secretions and the formation of an anal abscess. Because the content of such a crypt is always contaminated, it consists of fecal content, and half of its dry mass is bacteria. This so-called cryptoglandular theory, introduced by Hermann in 1880, is currently valid in proctology for the origin of a perianal abscess. Moreover, it proves that abscess and fistula - these are two phases of the same disease - the abscess is the acute phase, andIf the skin breaks through, a fistula is formed.

Rectal abscess: classification

It is important to be able to recognize the different types of abscesses as the treatment depends on the type of lesion. There are the following types of abscesses:

  • subcutaneous abscess (60-70%) - the abscess is formed superficially in the subcutaneous tissue around the anus
  • ischio-rectal abscess (20%) - develops when the purulent process penetrates through the external anal sphincter towards the ischio-rectal fossa
  • intersphincteric abscess (5%) - forms when pus accumulates in the intersphincteric space
  • superextension abscess (4%) called pelvic-rectal abscess - it arises in the course of a process spreading in the intersphincteric space above the level of the dentate line, as well as as a consequence of a fistula formed in the course of Crohn's disease, diseases in the peritoneal cavity (appendicitis , diverticulitis or adnexitis) or foreign body injuries of the rectum
  • submucosal abscess (1%)
  • anal space abscess - with the starting point in the posterior median gland, pierces through the external sphincter.

The anorectal space connects directly to both lateral ischio-rectal spaces and if effective treatment is not implemented at the right time, a so-called horseshoe abscess may develop!

Anal fistula: classification

Traditionally adopted Park's division into four main groups of fistulas, depending on their course in relation to the external anal sphincter:

  • intersphincteric fistulas
  • transsphincter fistulas
  • supraspinal fistulas
  • extra-sphincter fistulas

Fistulas located superficially constitute an additional group.

TheGoodsall rulecan help in assessing the course of the fistula, according to which the fistulas opening on the skin around the anterior half of the anus are usually straight, while those that open around the posterior half of the anus Anal openings usually have multiple external openings, and are curved or horseshoe-shaped. The Goodsall Rule is to apply to fistulas whose external opening is 3-5 cm from the anal margin. However, there are publications whose authors question the Goodsall rule in its entirety, pointing to numerous cases where it does not work.

Perianal abscess and anal fistula: symptoms

An abscess presents itself acutely as a painful thickening around the anus. The pain increases within a few days, and sometimes even within a dozen or so hours,depending on the size and depth of the abscess. The buttock around the anus may be enlarged. The symptoms are often very severe, the patient cannot sit or lie down. Often a "gagging" of purulent contents is felt inside the growing lump. There is fever, weakness and malaise. A characteristic feature of perianal abscesses is that the higher the abscess is in relation to the anus, the weaker the local symptoms and the more general symptoms.

After the abscess breakthrough, a foul-smelling content appears on the surface of the skin. Puncture of the abscess usually reduces the pain. The symptom of a fistula is chronic leakage of purulent contents staining underwear, pain during defecation and itching around the anus.

Perianal abscess and anal fistula: diagnosis

In addition to the physical examination and basic endoscopic examinations, such as sigmoidoscopy (simple and minimally invasive assessment of the end of the colon with a flexible endoscope) or anoscopy (evaluation of the anus with a transparent, short, rigid speculum), imaging examinations are performed to show the anatomy of the affected area and its exact location abscess and possible fistulas. These tests include magnetic resonance imaging and intrarectal endosonography, i.e. transrectal ultrasound. These highly specialized studies also allow for the prognosis of the course of the disease.

Rectal abscess and anal fistula: treatment

Fistulas and abscesses in the anus area have been present for mankind since the dawn of history, surgical treatment of fistulas has several thousand years of tradition, and surgical techniques were already described by the father of medicine - Hippocrates.

These diseases, however, are distinguished by a high degree of difficulty in treatment - fistula operations are rightly considered the most difficult part of proctology. This difficulty is caused by both the potential risk of damage to the anal sphincter and, consequently, fecal incontinence, and the significant percentage of postoperative recurrences - up to 30 percent, according to various literature data. If the abscess is superficial in an otherwise he althy person, an incision is made under local anesthesia on an outpatient basis. In an uncomplicated case, treatment with antibiotics is not necessary. They are recommended for patients with diabetes, leukemia, heart valve defects and those treated with immunosuppressants. In the case of extensive abscesses or abscesses occurring in the course of other diseases, as well as fistulas, surgical treatment is necessary.

Proper and accurate incision and emptying of the anal abscess (excluding light forms of subcutaneous abscess) always requires general anesthesia (anesthesia). It is necessary to open all chambers carefullyabscess that can penetrate really deeply and contain up to half a liter of foul-smelling purulent contents.

Proper incision of the abscess, emptying it of secretions and allowing its cavity to cleanse (drainage) brings immediate relief from ailments. An abscess usually heals quickly, but once it has healed, there is unfortunately a high probability of a fistula remaining - it is currently estimated to be around 40 percent. As part of the prevention of recurrence after spontaneous or surgical evacuation of an abscess, it is recommended to sit in a session, i.e. immerse the perianal area in a sitting position in disinfectant fluids, follow a diet that facilitates proper defecation, relaxants and painkillers.

Anal fistulas are treated surgically. Fistula operations should be performed in centers specialized in proctological operations. Anal fistula operations are most often performed under epidural anesthesia. Treatment does not end immediately after surgery. Part or all of the fistula wound remains uncut by the surgeon. Such a wound takes a long time to heal. After a stay of approximately one week in hospital, treatment is continued at home. The control tests are carried out by the doctor who operated on the patient. Such care lasts a minimum of 6 to 8 weeks after surgery. In recent years, procedures for clogging anal fistulas with the use of adhesives (e.g. on the basis of the patient's natural fibrin) and the so-called plugs made of biological material have been used. These treatments are not widely used in Poland due to the high price of the material and limited indications for selected cases.

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Gastrology