Anal fistula surgery: treatment options, continence and recovery

An anal fistula is a small tunnel that runs from inside the end of the bowel to an opening in the skin near the anus. Most develop after an anal abscess, a collection of pus, that did not heal properly (NHS). Less common causes include Crohn’s disease, diverticulitis, hidradenitis suppurativa, TB or HIV infection, and complications of earlier surgery near the anus.

Is it the same as a pilonidal sinus?

No. A pilonidal sinus is a small hole or tunnel at the top of the buttock crease, not next to the anus. It is more common in men and in people who sit for long periods, and it usually needs treatment only if it becomes infected (NHS). The two are sometimes confused because both can discharge pus.

Typical symptoms are skin irritation around the anus, constant throbbing pain that is worse when sitting or opening the bowels, a smelly discharge, and pus or blood when you pass stool. Swelling, redness and fever suggest an abscess (NHS).

Diagnosis starts with an examination of the anus and rectum, sometimes a proctoscopy, and often an ultrasound, MRI or CT scan to map the tunnel (NHS). Because fistulas rarely heal without treatment, most people need surgery. An active infection is drained first, and repair is planned once the swelling has gone down (Cleveland Clinic). If Crohn’s disease is the cause, the bowel condition needs treating alongside the fistula.

Surgery is usually done under general anaesthetic (NHS) and can take from five minutes to two hours, depending on how complex the fistula is (Cleveland Clinic). The main options are:

• Fistulotomy: the whole tunnel is cut open so it heals as a flat scar. It is the most common operation and suits fistulas that pass through little of the sphincter muscle (NHS).
• Seton: a surgical thread is placed through the tunnel and left for several weeks to keep it draining (NHS). A loose seton lets infection settle; a cutting seton is tightened over time to cut through the fistula gradually (Cleveland Clinic).
• Advancement flap: a flap of the rectal lining is pulled over the inner opening and stitched in place (Cleveland Clinic).
• LIFT: the surgeon separates the two sphincter muscles, divides and closes the tunnel between them, and brings the muscles back together (Cleveland Clinic).

Fibrin glue, fistula plugs, laser closure and endoscopic ablation are further options for selected fistulas (NHS), and a complex fistula may need a staged approach, with a seton first and a repair weeks or months later (Cleveland Clinic).

The anal sphincter muscles keep you continent, and a fistula often passes through part of them. That is why the choice of operation depends on how much muscle the tunnel crosses: cutting through a small amount is usually safe, while cutting through more risks weaker control (NHS).

Possible problems include difficulty controlling wind or holding in stool (Cleveland Clinic). Severe incontinence is rare, and every effort is made to prevent it (NHS). Flap repair and LIFT were developed to avoid cutting the sphincter, accepting a lower chance of healing in exchange. Tell your surgeon about any existing leakage, previous anal surgery or childbirth injuries before the plan is made.

Before surgery the surgeon examines you and reviews any MRI or ultrasound that maps the tunnel. Bring a list of your medicines, particularly blood thinners, and follow the fasting instructions for the anaesthetic.

Many fistula operations are day cases, so arrange for someone to drive you home afterwards (Cleveland Clinic). Stock up on high-fibre foods and plenty of fluids so that your first bowel movements after surgery are soft.

Many people do not need to stay in hospital overnight (NHS). Recovery varies: some recover within a few weeks, while others need several months to heal fully (Cleveland Clinic). Your activity afterwards depends on which procedure was done.

Mild pain, swelling and some drainage are normal while a seton is in place. Over-the-counter pain relief, warm sitz baths, keeping the area clean, a high-fibre diet, plenty of fluids and avoiding heavy lifting for a short time all help (Cleveland Clinic). A seton may stay in for weeks or months, and the swelling it treats can take two to three months to settle (Cleveland Clinic).

Every option carries some risk, and the level depends on where the fistula lies and which procedure is used (NHS). An infection may need a course of antibiotics, and occasionally hospital treatment.

The fistula can sometimes come back despite surgery, and recurrence is one of the main risks, often showing first as infection (Cleveland Clinic). Other possible problems include bleeding, ongoing pain or skin irritation, continued drainage, and the continence problems described above (Cleveland Clinic).

Contact the surgical team promptly if you have any of the following after surgery (Cleveland Clinic):

• fever or chills
• pain that is getting worse
• heavy bleeding
• swelling, redness or skin discolouration around the anus
• foul-smelling drainage, or new discharge suggesting the fistula has returned
• constipation that does not improve

Increasing swelling around the anus or signs of a new abscess also need checking quickly (Cleveland Clinic).

Fistulotomy is the most effective treatment for many anal fistulas (NHS) and usually has a high success rate (Cleveland Clinic). An advancement flap has a lower success rate but avoids cutting the sphincter muscles, and LIFT has shown promising results, though more research is needed (NHS).

Sources differ on the newer options. Fibrin glue is generally less effective than fistulotomy for simple fistulas and its results may not last (NHS), while the Cleveland Clinic notes that glue and plugs are rarely used because of high failure rates and that laser closure has no well-established success rate (Cleveland Clinic). Ask your surgeon why a particular option is recommended for your fistula.

The table summarises how the main options trade healing against sphincter protection.

The cost in Cairo depends on the type of fistula and the procedure, whether an MRI is needed first, whether the treatment is staged with a seton and a later repair, the hospital and room class, the anaesthetic and the follow-up visits. A complex or recurrent fistula usually means more than one operation.

Ask for a written quote that sets out each stage and the follow-up included. Dr. Yasser, FRCS (Edinburgh, 1996), also performs hernia repair and appendectomy among his general surgery work. You can book a consultation with Dr. Yasser for an examination and a plan that puts continence first.