Anal Fistulas and Fissures: Background, Pathophys... https://emedicine.medscape.com/article/776150-...

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Anal Fistulas and Fissures

Updated: Dec 28, 2017
Author: Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE; Chief
Editor: Barry E Brenner, MD, PhD, FACEP more...

OVERVIEW

Background
An anal fissure is a superficial linear tear in the anoderm that is distal to
the dentate line. Anal fissures are often associated with local trauma
such as the passage of hard stools or anal trauma, but can also be due to
secondary causes such as inflammatory bowel disease. Anal fissures are
among the most common anorectal disorders in the pediatric population.
Adults are also affected, although it is thought to be underreported in the
adult population.

Fissures are defined as acute if present for less than 8 weeks, and they
are defined as chronic if present for more than at 8-12 weeks weeks. [1]

An anal fistula is an inflammatory tract between the anal canal and the
skin. The 4 categories of fistulas, based on the relationship of fistula to
sphincter muscles, are intersphincteric, transsphincteric,
suprasphincteric, and extrasphincteric. [2]

An anal fistula can be categorized as either simple or complex. A simple

anal fistula includes low transsphincteric and intersphincteric fistulas
that cross 30% of the external sphincter. Fistulas are complex if the
primary track includes high transsphincteric fistulas with or without a
high blind tract, suprasphincteric and extrasphincteric fistulas,
horseshoe fistulas, multiple tracks, anteriorly lying track in a female
patient, and those associated with inflammatory bowel disease, radiation,

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malignancy, preexisting incontinence, or chronic diarrhea. Note the

image below.

Anal fistulas and fissures. This patient reported constipation.

Pathophysiology and Etiology

Anal fissure

In anal fissures, the anus distal to the dentate line is involved. About
90% of anal fissures occur in the posterior midline. Ten percent are
found in the anterior midline, more commonly in women. Only 1% occur
off midline.

While the exact etiology is often unknown, passage of hard stools and
anal trauma are often associated with anal fissures. Other causes of anal
fissures can be observed in patients with chronic diarrhea, during
childbirth, and those with a habitual use of cathartics. When an anal
fissure occurs in an atypical location, it may be associated with syphilis
and other sexually transmitted diseases, tuberculosis, [3] leukemia, [4]
inflammatory bowel disease such as Crohn disease, previous anal
surgery, HIV disease, and anal cancer. Once a fissure is formed, ongoing
pain can cause the internal analsphincter to spasm (hypertonicity), which
causes the wound edges of the fissure to pull apart, impairing
healing. Local ischemia is also thought to contribute to anal fistulas,
especially in the posterior quadrant where blood flow is significantly less
than other quadrants. As the anal sphincter continues to spasm,
increased pressures are thought to further impede blood flow. [5, 1]

Evidence suggests that blood flow to the anal canal and internal anal
sphincter tone play a role in the development and healing of anal

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fissures. Decreased blood flow has been described in chronic, nonhealing

fissures. Hypertonicity of the internal sphincter may also cause
decreased blood flow in the area of a fissure. [6, 7, 8]

Anal fistula

Most anal fistulas originate in anal crypts, which become infected, with
ensuing abscess formation. When the abscess is opened or when it
ruptures, a fistula is formed. An anal fistula can have multiple accessory
tracts complicating its anatomy.

Other causes of anal fistulas include opened perianal or ischiorectal

abscesses, which drain spontaneously through these fistulous tracts.
Fistulas are also found in patients with inflammatory bowel disease,
particularly Crohn disease. [9] The incidence of fissures in Crohn disease
is 30-50%. Perianal activity often parallels abdominal disease activity,
but it may occasionally be the primary site of active disease.

Anal fistulas can also be associated with diverticulitis, foreign-body

reactions, actinomycosis, chlamydia, lymphogranuloma venereum (LGV),
syphilis, tuberculosis, [3] radiation exposure, and HIV disease.
Approximately 30% of patients with HIV disease develop anorectal
abscesses and fistulas.

Anal fistulas are classified into the following 4 general types:

Intersphincteric - Through the dentate line to the anal verge,

tracking along the intersphincteric plane, ending in the perianal
skin

Transsphincteric - Through the external sphincter into the

ischiorectal fossa, encompassing a portion of the internal and
external sphincter, ending in the skin overlying buttocks

Suprasphincteric - Through the anal crypt and encircling the entire

sphincter, ending in the ischiorectal fossa

Extrasphincteric - Starting high in the anal canal, encompassing

the entire sphincter and ending in the skin overlying the buttocks

Epidemiology
Anal fissures affect males and females equally; however, an anterior
fissure is more likely to develop in women (25%) than in men (8%). [5]

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Although anal fissures are the most common cause of rectal bleeding in
infants, they are primarily seen in young adults. Eighty-seven percent of
people with a chronic anal fissure are between the ages of 20 and 60
years. Anal fissures in children may indicate sexual abuse.

Anal fistulas are a complication of anorectal abscesses, which are more

common in women than in men. For reasons of intrinsic anatomy,
rectovaginal fistulas are found only in women. Approximately 30-50% of
patients with an anorectal abscess form an anal fistula. [10] and
approximately 80% of anal fistulas arise from anorectal infection. [11]

Prognosis
Approximately half of uncomplicated fissures resolve in 2-4 weeks with
supportive care. [1] Fissures that heal with conservative treatment can
recur, depending on the type of treatment the patient has undergone
(ranging from 16% to more than 50%). [5] Chronic anal fissures
frequently require surgical treatment.

Surgical treatment of anal fissures is associated with some degree of

incontinence in approximately 14% of patients. [12]

Prognosis for fistulas is excellent after surgery, with recurrence rates

around 7-21% depending on the complexity and location of the fistula.
[11, 13] Use of fibrin glue or fistula plug has variable success rates.

Clinical Presentation

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