Excision of a pararectal fistula

Pararectal fistulas most often form after exacerbations of purulent paraproctitis, when there is prolonged inflammation in the pararectal tissue. A characteristic sign is the fistulous tract – a pathological channel between the rectum and surrounding tissue, which never heals on its own. The problem can only be resolved surgically.

Causes of pararectal fistula

A rectal fistula is a consequence of chronic inflammation. 95% of all cases of pararectal fistulas are diagnosed in patients after another exacerbation of chronic paraproctitis. Other possible causes of the appearance of a rectal fistula include:

• Crohn’s disease;
• anal fissures;
• chronic constipation (hard stools contribute to microtrauma);
• malignant formations of the rectum;
• intestinal hernias;
• as a result of self-treatment of haemorrhoids, proctitis, and other pathologies of the anal area.

Symptoms of the Disease

The clinical picture of pararectal fistulas is quite vivid, and the quality of life of patients drops significantly. Symptoms will vary depending on whether the fistula is internal or external. The signs of an external anal fistula are as follows:

• thickening, skin irritation in the perianal area due to constant friction, presence of bacterial flora;
• fistula opening in the form of a funnel;
• discharge from the fistula funnel, which is unpleasant in odor, may be purulent or mucopurulent;
• inflammatory symptoms (swelling, redness of the skin around the anal opening).

Internal localization of fistulas also creates a lot of troubles. Such fistulas cause abscesses that are accompanied by fever, discomfort, burning, itching and intense pain. In severe cases of the disease, it becomes difficult for a person to control the act of defecation – incontinence appears. This greatly affects the quality of a person’s social life. Patients also complain of pain that increases when sitting, as well as when moving or sneezing or coughing. Discharge of blood, pus or mucus may appear from the anus.

Diagnostics of perirectal fistula

In most cases, the diagnosis is not in doubt by an experienced doctor already during the examination of the patient. A detailed history of the disease and complaints are obtained, and the perianal area is examined. During a digital examination, the specialist finds an opening in the perianal area, from which, when pressed, pus is released, or, less commonly, mucus.

For effective treatment, it is important to determine the fistula tract during the examination process. For this, not only a digital examination is used, but also inspection with mirrors, probing, anoscopy, and other diagnostic methods. Among them:

• Probing – with its help, the doctor can assess the depth of the fistula canal, its connection with the intestine and anal sphincter, identify additional branches, etc.;
• Rectosigmoidoscopy – using endoscopic techniques, it is possible to exclude neoplasms, assess the condition of the mucosa, take a tissue sample for subsequent laboratory study;
• Fistulography – contrast is introduced through the anus, after which X-rays are taken (helps determine the presence of pockets, the size, and location of the fistula tract);
• Transrectal ultrasound examination – the method is good for its simplicity and safety for the patient;
• Computed tomography or magnetic resonance imaging.

A woman diagnosed with a pararectal fistula will certainly be referred to a gynecologist. This is necessary to rule out the presence of a pathological tract connecting the rectum and vagina.

Accurate diagnosis, appropriate equipment, and coordinated work of specialists help to develop a justified treatment plan. The outcome depends on the location of the fistula, the condition of the sphincter, comorbidities, and previous interventions. Before surgery, the likelihood of recurrence, the risk of continence impairment, and possible alternatives are discussed.

Treatment of pararectal fistulas

Coloproctologists unanimously advise not to delay the treatment of chronic paraproctitis, as it is very difficult to deal with its complications. The prolonged presence of a fistula is a serious risk factor for malignant neoplasms. Also, as a result of a series of exacerbations and remissions of the disease, scar tissue forms, which subsequently leads to sphincter insufficiency or narrowing.

Contraindications for surgery include decompensation of chronic diseases (for example, diabetes), acute infectious conditions, severe kidney dysfunction, and the severe condition of the patient. Since the surgery is performed on a scheduled basis, the person has some time to address health issues.

There are several options for surgical treatment of pararectal fistulas. The choice of a specific method depends on the stage of the disease, the presence of complications, and many other individual characteristics of the patient. Here are just some of the possible operations:

• ligation method;
• excision of the fistula along its entire length;
• filling;
• laser surgery;
• repair of the internal opening of the fistula.

Considering the characteristics of the perianal area (in particular, the abundance of nerve fibers), special attention is paid to the issue of pain relief. In our clinic, spinal-epidural anesthesia is used, and the medications employed provide effective pain relief even in the postoperative period. After surgery, it is necessary to maximally eliminate risk factors for the recurrence of paraproctitis, which is the main cause of fistula formation. One should review their diet, incorporate regular physical activity into their life, and timely consult a doctor for help.