ANAL ABCESS AND FISTULA
What is an anal abcess?
An anal abscess is an infected cavity filled with pus found near the anus or rectum.
What is an anal fistula?
An anal fistula (also called fistula-in-ano) is frequently the result of a previous or current anal abscess, occurring in up to 50% of patients with abscesses. Normal anatomy includes small glands just inside the anus. Occasionally, these glands get clogged and potentially can become infected, leading to an abscess. The fistula is a tunnel that forms under the skin and connects the infected glands to the abscess. A fistula can be present with or without an abscess and may connect just to the skin of the buttocks near the anal opening. Other situations that can result in a fistula include Crohn’s disease, radiation, trauma and malignancy.
How does someone get an anal abscess or a fistula?
The abscess is most often a result of an acute infection in the internal glands of the anus. Occasionally, bacteria, fecal material or foreign matter can clog the anal gland and create a condition for an abscess cavity to form. Other medical conditions can make these types of infections more likely.
After an abscess drains on its own or has been drained (opened), a tunnel (fistula) may persist, connecting the infected anal gland to the external skin. This typically will involve some type of drainage from the external opening and occurs in up to 50% of abscesses. If the opening on the skin heals when a fistula is present, a recurrent abscess may develop.
What are the specific signs or symptoms of an abscess or fistula?
A patient with an abscess may have pain, redness or swelling in the area around the anal area. Fatigue, general malaise, as well as accompanying fever or chills are also common. Similar signs and symptoms may be present when patients have a fistula, with the addition of possible irritation of the perianal skin or drainage from an external opening.
Is any specific testing necessary to diagnose an abscess or fistula?
No. Most anal abscesses or fistula-in-ano are diagnosed and managed on the basis of clinical findings. Occasionally, additional studies such as ultrasound, CT scan, or MRI can assist with the diagnosis of deeper abscesses or the delineation of the fistula tunnel to help guide treatment.
What is the treatment of an anal abscess?
The treatment of an abscess is surgical drainage under most circumstances. An incision is made in the skin near the anus to drain the infection. This can be done in a doctor’s office with local anesthetic or in an operating room under deeper anesthesia. Hospitalization may be required for patients prone to more significant infections such as diabetics or patients with decreased immunity.
Are antibiotics required to treat this type of infection?
Antibiotics alone are a poor alternative to drainage of the infection. For uncomplicated abscesses, the addition of antibiotics to surgical drainage does not improve healing time or reduce the potential for recurrences. There are some conditions in which antibiotics are indicated, such as for patients with compromised or altered immunity, some cardiac valvular conditions or extensive cellulitis. A comprehensive discussion of your past medical history and a physical exam are important to determine if antibiotics are indicated.
What is the treatment of an anal fistula?
Surgery is almost always necessary to cure an anal fistula. Although surgery can be fairly straightforward, it may also be complicated, occasionally requiring staged or multiple operations. Consider identifying a specialist in colon and rectal surgery who would be familiar with a number of potential operations to treat the fistula.
The surgery may be performed at the same time as drainage of an abscess, although sometimes the fistula doesn’t appear until weeks to years after the initial drainage. If the fistula is straightforward, a fistulotomy may be performed. This procedure involves connecting the internal opening within the anal canal to the external opening, creating a groove that will heal from the inside out. This surgery often will require dividing a small portion of the sphincter muscle which has the unlikely potential for affecting the control of bowel movements in a limited number of cases.
Other procedures include placing material within the fistula tract to occlude it or surgically altering the surrounding tissue to accomplish closure of the fistula, with the choice of procedure depending upon the type, length, and location of the fistula. Most of the operations can be performed on an outpatient basis, but may occasionally require hospitalization.
What is the recovery like from surgery?
Pain after surgery is controlled with pain pills, fiber and bulk laxatives. Patients should plan for time at home using sitz baths and attempt to avoid the constipation that can be associated with prescription pain medication. Discuss with your surgeon the specific care and time away from work prior to surgery to prepare yourself for post-operative care.
Can the abscess or fistula recur?
If adequately treated and properly healed, both are unlikely to return. However, despite proper and indicated open or minimally invasive treatment, both abscesses and fistulas can potentially recur. Should similar symptoms arise, suggesting recurrence, it is recommended that you find a colon and rectal surgeon to manage your condition.
What are anal warts?
Anal warts (also called "condyloma acuminata") are a condition that affects the area around and inside the anus. They may also affect the skin of the genital area. They first appear as tiny spots or growths, perhaps as small as the head of a pin, and may grow quite large and cover the entire anal area. Usually, they do not cause pain or discomfort to afflicted individuals and patients may be unaware that the warts are present. Some patients will experience symptoms, such as itching, bleeding, mucus discharge and/or a feeling of a lump or mass in the anal area.
What causes anal warts?
They are caused by the human papilloma virus (HPV), which is transmitted from person to person by direct contact. HPV is considered a sexually transmitted disease (STD). You do not have to have anal intercourse to develop anal warts.
Do anal warts always need to be removed?
Yes. If they are not removed, the warts usually grow larger and multiply. Left untreated, the warts may lead to an increased risk of cancer in the affected area.
What treatments are available?
If warts are very small and are located only on the skin around the anus, they may be treated with a topical medication. They may also be treated by freezing the warts with liquid nitrogen or removed surgically. Surgery typically involves cutting or burning the warts off. While this provides immediate results, it must be performed using either a local anesthetic - such as novocaine - or a general or spinal anesthetic, depending on the number and exact location of warts being treated. It is important that an internal anal examination with an instrument called an anoscope be done by your treating physician to ensure you do not have any inside the anal canal (internal anal warts). Internal anal warts may not be as suitable for treatment by topical medications, and may need to be treated surgically. Additionally, your physician may wish to examine the entire pelvic region to include the vaginal or penile area to look for other warts that may require treatment.
Must I be hospitalized for surgical treatment?
Surgical treatment of anal warts is usually performed as outpatient surgery.
How much time will I lose from work after surgical treatment?
Most people are moderately uncomfortable for a few days after treatment and pain medication may be prescribed. Depending on the extent of the disease, some people return to work the next day, while others may remain out of work for several days to weeks.
Will a single treatment cure the problem?
When warts are extensive, your surgeon may wish to perform the surgery in stages. Additionally, recurrent warts are common. The virus that causes the warts can live concealed in tissues that appear normal for several months before another wart develops. As new warts develop, they usually can be treated in the physician's office. Sometimes new warts develop so rapidly that office treatment would be quite uncomfortable. In these situations, a second and, occasionally, third outpatient surgical visit may be recommended.
How long is treatment usually continued?
Follow-up visits are necessary at frequent intervals for several months after all warts appear to be gone, to be certain that no new warts occur.
What can be done to avoid getting these warts again?
In some cases, warts may recur repeatedly after successful removal, since the virus that causes the warts often persists in a dormant state in body tissues. Discuss with your physician how often you should be evaluated for recurrent warts. Abstain from sexual contact with individuals who have anal (or genital) warts. Since many individuals may be unaware that they suffer from this condition, sexual abstinence, condom protection or limiting sexual contact to single partner will reduce your potential exposure to the contagious virus that causes these warts. As a precaution, sexual partners ought to be checked for warts and other sexual transmitted diseases, even if they have no symptoms.
What are the symptoms?
Symptoms vary from a small dimple to a large painful mass. Often the area will drain fluid that may be clear, cloudy or bloody. With infection, the area becomes red, tender, and the drainage (pus) will have a foul odor. The infection may also cause fever, malaise, or nausea.
There are several common patterns of this disease. Nearly all patients have an episode of an acute abscess (the area is swollen, tender, and may drain pus). After the abscess resolves, either by itself or with medical assistance, many patients develop a pilonidal sinus. The sinus is a cavity below the skin surface that connects to the surface with one or more small openings or tracts. Although a few of these sinus tracts may resolve without therapy, most patients need a small operation to eliminate them.
A small number of patients develop recurrent infections and inflammation of these sinus tracts. The chronic disease causes episodes of swelling, pain, and drainage. Surgery is almost always required to resolve this condition.
How is pilonidal disease treated?
The treatment depends on the disease pattern. An acute abscess is managed with an incision and drained to release the pus, and reduce the inflammation and pain. This procedure usually can be performed in the office with local anesthesia. A chronic sinus usually will need to be excised or surgically opened.
Complex or recurrent disease must be treated surgically. Procedures vary from unroofing the sinuses to excision and possible closure with flaps. Larger operations require longer healing times. If the wound is left open, it will require dressing or packing to keep it clean. Although it may take several weeks to heal, the success rate with open wounds is higher. Closure with flaps is a bigger operation that has a higher chance of infection; however, it may be required in some patients. Your surgeon will discuss these options with you and help you select the appropriate operation.
What care is required after surgery?
If the wound can be closed, it will need to be kept clean and dry until the skin is completely healed. If the wound must be left open, dressings or packing will be needed to help remove secretions and to allow the wound to heal from the bottom up.
After healing, the skin in the buttocks crease must be kept clean and free of hair. This is accomplished by shaving or using a hair removal agent every two or three weeks until age 30. After age 30, the hair shaft thins, becomes softer and the buttock cleft becomes less deep.
What is Pruritus Ani (proo-rí-tus a-ní)?
Itching around the anal area is called pruritus ani. This condition results in a compelling urge to scratch.
What causes this to happen?
Several factors may be at fault. A common cause is excessive moisture in the anal area. Moisture may be due to perspiration or a small amount of residual stool around the anal area. Pruritis ani may be a symptom of other common anal conditions such as hemorrhoids and anal fissures. The initial condition can be made worse by scratching, vigorous cleansing of the area or overuse of topical treatments.
In some individuals pruritus ani may be caused by eating certain foods, smoking and drinking alcoholic beverages, especially beer and wine. Food items that have been associated with pruritus ani include:
- Coffee, Tea
- Carbonated beverages
- Milk products
- Tomatoes and tomato products such as Ketchup
Does Pruritus Ani result from lack of cleanliness?
Cleanliness is almost never a factor. However, the natural tendency once a person develops this itching is to wash the area vigorously and frequently with soap and a washcloth. This almost always makes the problem worse by damaging the skin and washing away protective natural oils.
What can be done to make this itching go away?
A careful examination by a colon and rectal surgeon or other physician may identify a definite cause for the itching. Your physician can recommend treatment to eliminate the specific problem. Treatment of pruritus ani may include these three points.
AVOID MOISTURE in the anal area:
- Apply either a few wisps of cotton, a 4 x 4 gauze or some cornstarch powder to keep the area dry.
- Avoid all medicated, perfumed and deodorant powders.
AVOID FURTHER TRAUMA to the affected area:
- Do not use soap of any kind on the anal area.
- Do not scrub the anal area with anything – even toilet paper.
- For hygiene, it is best to rinse with warm water and pat the area dry. Use wet toilet paper, baby wipes or a wet washcloth to blot the area clean. Never rub.
- Try not to scratch the itchy area. Scratching produces more damage, which in turn makes the itching worse. For individuals that experience irresistible itching at night, wearing socks on the hands may be helpful.
- USE ONLY MEDICATIONS AS DIRECTED BY YOUR PHYSICIAN. Apply prescription medications sparingly to the skin around the anal area and avoid rubbing. Prolonged use of prescribed or over the counter topical medications may result in irritation or skin dryness that can make the condition worse.
How long does this treatment usually take?
Most people experience some relief from itching within a week. If symptoms do not resolve after 6 weeks, a follow-up appointment with your colon and rectal surgeon may be needed.