An anal fistula is a condition that begins with an abscess around the anal area and eventually forms a draining tunnel under the skin. This problem significantly affects quality of life and most often requires surgical treatment.
Although the use of laser technology in anal fistula treatment has gained popularity in recent years and initially created excitement among physicians and patients, its high recurrence rates—especially in complex fistulas—and complications such as anal stenosis and sphincter dysfunction have brought its effectiveness into question. Today, the most appropriate surgical method is selected based on the fistula’s structure and the degree of sphincter involvement.
What Is an Anal Fistula?
Anal fistulas typically develop as a result of perianal abscesses. Although the words “fissure” and “fistula” may sound similar, they refer to completely different conditions.
A fissure is a crack in the anal skin, whereas a fistula is an infected tunnel that forms after an abscess and creates an abnormal connection between two surfaces. The tunnel usually develops due to blockage of the anal glands. After the abscess drains, a persistent tract may remain between the internal gland and the outer skin, leading to continuous discharge, pain, and irritation.
What Are the Symptoms of an Anal Fistula?
Common symptoms reported by patients include:
- Discharge and foul odor around the anal area
- Swelling, redness, and warmth
- Pain while sitting, walking, or during defecation.
- Bleeding or pus during defecation
- Recurrent abscess episodes
Without treatment, new abscesses and fistula tracts may form, causing the condition to become complex.
What Causes an Anal Fistula?
Anal fistulas occur at similar rates in women and men. While there is no strict age range, they are most commonly seen in adults aged 20–50.
Common causes include:
- Previous perianal abscess
- Chronic constipation or diarrhea
- Inflammatory bowel diseases (Crohn’s disease, ulcerative colitis)
- Prolonged sitting
- Poor hygiene, excessive sweating, and moisture
- Rarely, trauma or tumors
During summer months, increased heat and humidity can raise the risk of bacterial infections around the anal area, leading to a temporary increase in fistula cases.
How Is an Anal Fistula Diagnosed?
Accurate diagnosis is essential for proper treatment. Diagnosis is primarily based on medical history and physical examination. However, pelvic MRI is necessary to evaluate the structure, depth, and sphincter involvement of the fistula. MRI allows the surgeon to map the fistula tract precisely.
Anal fistulas are classified into two groups:
- Simple fistulas: Minimal or no involvement of the sphincter muscle
- Complex fistulas: Involve the muscle, may have multiple tracts or openings
The treatment method is chosen according to this classification.
How Is Anal Fistula Surgery Performed?
The goal of anal fistula treatment is complete eradication of the infection while preserving the sphincter muscle. Medication alone is not sufficient; surgery is necessary.
In simple cases, the fistulotomy procedure is used, in which the tract is opened to allow healing from the inside out.
Complex cases require techniques such as seton placement, LIFT, flap repair, or laser treatment.
1. Traditional Surgery (Fistulotomy)
- The skin and part of the muscle over the fistula are opened, connecting the internal and external openings.
- The tract is left open to heal naturally.
- It is the most effective and permanent solution for simple, low-level fistulas.
- Risk: Excessive division of muscle may cause gas or stool incontinence, making surgical experience critical.
2. Seton Placement
Commonly preferred for complex fistulas.
- A seton (special thread or elastic band) is placed through the fistula tract.
- It helps drain infection and gradually reduces the size of the tract.
- Types include loose seton, cutting seton, and adjustable seton.
Loose seton:
- Usually removed after 6–8 weeks, followed by definitive surgery.
- Less painful.
Cutting seton:
- Gradually cuts through the tissue and eliminates the need for a second operation.
- More painful during dressing changes.
Adjustable seton:
- Initially placed loosely and tightened during dressing changes.
- Lower impact on sphincter function.
The technique is selected based on the patient’s anatomy and fistula type.
3. LIFT (Ligation of Intersphincteric Fistula Tract)
- A sphincter-sparing technique.
- The tract between the sphincter muscles is tied off and sealed.
- Success rate is around 70%, with shorter healing time.
4. Endoanal Advancement Flap
- Used in complex fistulas.
- The internal opening is closed using healthy rectal mucosa.
- The sphincter is preserved.
- Recurrence rate ranges from 15–50%, depending mainly on the surgeon’s experience.
5. Fibrin Glue and Fistula Plug
- The tract is filled with biological materials to seal it.
- Considered a minimally invasive option for selected patients with high risk of sphincter injury.
- Typically combined with other procedures due to high recurrence rates.
6. Laser Treatment for Anal Fistula
- A method used in recent years.
- A laser probe is inserted into the tract, delivering 360° energy to seal the inner lining.
Advantages:
- Less pain
- Faster recovery
- Same-day discharge
Disadvantages:
- Very low success rate in complex fistulas
- Risk of anal stenosis and sphincter injury due to thermal damage
Because of these limitations, the use of laser therapy is gradually declining.
7. Flap-Based Anal Fistula Surgery
Recent studies worldwide have increased interest in flap techniques.
- The primary step is removing the main fistula tract without damaging surrounding tissue.
- Advanced visualization tools improve success rates and help preserve the sphincter.
- In the second step, the internal opening is closed using a flap.
This method—commonly used in our practice—offers a comfortable recovery process for both patient and surgeon. Dressing changes are shorter and less painful, and the risk of gas or stool incontinence is significantly lower because the muscle is not harmed.
Postoperative Recovery After Anal Fistula Surgery
- Most patients are discharged on the same day.
- Mild pain and drainage are normal during the first days.
- Warm sitz baths after bowel movements are recommended.
- Avoid constipation, drink plenty of water, and eat a fiber-rich diet.
- Follow-up visits should not be missed.
Anal fistula is a condition that should not be neglected and has a direct impact on quality of life. Treatment success depends on the type of fistula, the surgeon’s experience, and choosing the correct surgical technique. Early evaluation reduces recurrence rates and ensures faster healing.
