Anal abscess and anal fistula treatment in Baku

An abscess usually starts in a tiny gland in the wall of the anal canal: its duct becomes blocked, pus collects inside, and the pus then forces its way between the muscles and forms a painful swelling next to the anus. This is the acute stage of the disease.

Once the abscess has emptied, the track the pus followed does not always close, and a narrow tunnel remains that connects the inside of the bowel with the skin next to the anus. This is the chronic stage, an anal fistula (also known as fistula-in-ano; locally it is sometimes called “svish”).

Because one end of the fistula opens into the bowel, new bacteria keep getting into the tunnel, and over time its wall hardens and becomes lined on the inside with a thin layer of tissue. That is why a fistula does not close with medication: even if the outer opening seals over for a while, pus builds up again underneath. We explain in detail how an anal abscess develops, its types and its first signs in our article What is an anal abscess?

An abscess shows itself through throbbing pain that keeps getting worse, a red, hot and firm swelling next to the anus, fever and chills. Sitting, walking and going to the toilet make the pain worse. With a deep abscess, there may be no visible swelling on the outside; instead, the main signs are a feeling of heaviness in the rectum and a high temperature.

With a fistula, there is a small opening (sometimes several) near the anus that leaks pus or blood-streaked discharge from time to time. It stains your underwear and makes the skin itch. When the opening closes, the pain and swelling come back; when it opens, they ease, so the condition comes and goes in waves. In rare cases, gas or stool comes out through the opening.

These symptoms are easily confused with other conditions: a painful lump next to the anus may be a thrombosed hemorrhoid, and bloody discharge can also be a sign of an anal fissure or a polyp. Only an examination can give you a definite answer.

In most cases, an abscess starts when an anal gland becomes infected, and no obvious outside cause is found. For planning treatment, though, it is important to know the conditions that raise the risk: an anal fissure (sometimes called an anal tear) that was not treated in time, constipation and diarrhea, proctitis, tears during childbirth and injuries to the anal area, diabetes, and treatments that weaken the immune system.

If abscesses keep coming back or appear in several places, you should be checked for Crohn's disease, because in that case the fistula is treated together with a gastroenterologist.

The disease has two stages: acute (abscess) and chronic (fistula). The treatment method depends on how deep the abscess is and how far it has spread, and on how the fistula relates to the sphincter. We describe the types of abscess (superficial, deep, horseshoe-shaped) in a separate article; here we focus on the types of fistula, which matter when choosing the operation.

The anus is closed by two sphincters, the internal and the external. They are what allow us to hold in gas and stool. Fistulas are divided into four types based on how they relate to these muscles:

In practice, we divide fistulas into simple and complex. A simple (low) fistula is a single tunnel that passes through only a small part of the sphincter. A fistula is considered complex (high) if it involves a large part of the sphincter, branches, has several openings, keeps coming back or has developed in the setting of Crohn's disease. In women, fistulas at the front of the anus call for extra caution, because the sphincter is thinner in this area. The treatment method is chosen precisely on the basis of this distinction.

An abscess cannot wait. Do not delay — seek urgent care if:

• you have a painful swelling next to the anus together with fever or chills;
• the pain gets stronger over a few hours and keeps you from sitting or sleeping;
• you cannot pass urine;
• the redness and swelling spread to the perineum, buttock, scrotum or labia, or the skin turns dark;
• you have diabetes or take medication that weakens the immune system.

If a high temperature comes with severe weakness, a racing heart or confusion, go to the nearest emergency room.

Do not take antibiotics and wait for the abscess to settle down: the medication does not clear out the pus-filled cavity, and any delay allows the pus to spread into deeper layers and damage the sphincter. Do not squeeze or pierce the abscess at home, and do not wait with warm compresses for it to “come to a head”. Once an abscess is found, opening it is not put off — it is usually done the same day.

It is natural to feel uneasy about a proctological exam, but there is nothing to be embarrassed about at your appointment. First, we ask about your symptoms, any constipation or diarrhea, and other health conditions you may have. The examination takes place in a separate room, usually while you lie on your side, and often takes only a few minutes.

An abscess can often be diagnosed simply by looking. If the pain is very severe, we do not force a finger examination: the perineal area is gently checked by hand, and an ultrasound is done if needed.

With a fistula, we need an accurate “map”: where the tunnel starts, which part of the sphincter it passes through and whether it has branches. To build this map, we choose the tests you need:

• anoscopy: a look inside the anal canal with a small instrument to find the internal opening of the fistula;
• probing: gently tracing the tunnel with a thin, blunt-tipped probe; this is often done during the operation, under anesthesia;
• ultrasound or pelvic MRI: for complex, recurrent or branching fistulas;
• anal manometry (sphincterometry): measuring the strength of the sphincter, in selected cases;
• colonoscopy: if Crohn's disease is suspected or if it is recommended for your age.

An anal abscess and a fistula do not heal with medication: the source of the inflammation has to be removed surgically. Medications support the treatment and make recovery easier.

Conservative treatment

• Antibiotics play only a supporting role: the doctor prescribes them alongside drainage when the inflammation has spread to the surrounding tissue, in people with diabetes or when the immune system is weak.
• Painkillers and a diet that softens the stool make going to the toilet easier; preventing constipation is especially important during this time.
• Warm sitz baths and good hygiene help keep the wound clean.
• Treating the underlying cause: proctitis, Crohn's disease, and in children, intestinal worms and constipation. A fistula related to Crohn's disease is treated together with a gastroenterologist.

We explain in detail when medication is needed and when surgery is needed on our surgical and conservative treatment page.

Surgical and minimally invasive methods

Opening and draining the abscess. The procedure is usually done under general anesthesia: you feel no pain, and the surgeon can fully examine the cavity and drain all of the pus. An incision is made in the skin next to the anus, the pus is drained, the cavity is rinsed and drained, and a sterile dressing is applied. The wound is left open and heals from the inside out. If no fistula is found during the operation, you need to come for follow-up visits until the wound has healed. If a fistula is found, depending on its type, its treatment is planned either for the same session or for after the inflammation has settled.

Anal fistula surgery. Only surgery can get rid of a fistula. The surgical method is chosen according to the type of fistula: fistulotomy, fistulectomy, a seton or sphincter-sparing techniques. Which method is right for you is decided after the examination. In plain words:

• fistulotomy: the tissue over the tunnel is opened, and the tunnel heals from the inside as an open wound; it is usually used for simple, low fistulas;
• fistulectomy: the entire tunnel is cut out;
• seton: a special soft thread is passed through the tunnel; the pus drains freely, the inflammation calms down, and in a complex fistula it makes staged, sphincter-sparing treatment possible;
• sphincter-sparing techniques: methods that aim to close the tunnel without cutting the muscle; they are considered for complex, high fistulas.

Whichever approach is chosen, the main priority stays the same: to heal the fistula and protect the sphincter, so that you do not lose the ability to hold in gas and stool. With a simple fistula, this balance is easier to achieve. With a complex fistula, treatment is sometimes carried out in two stages, because a sphincter that has been cut in haste is difficult to repair later.

If you also have hemorrhoids, an anal fissure or a polyp in addition to the fistula, we can often treat them in the same session, under a single anesthetic, when your condition allows. We call this a combined (“bouquet”) surgery.

Recovery depends on the extent of the operation. The table shows what you can expect on average; we will give you exact timelines after the examination.

We decide together at a follow-up visit, based on how your wound is healing, when you can get back to sports, swimming and sexual activity.

1. Do not put off treating an anal fissure or hemorrhoids. A fissure that does not heal can let bacteria into the tissue; learn to recognize the symptoms of an anal fissure early.
2. Avoid constipation and diarrhea. Aim for soft, regular stools: fiber-rich food, physical activity and fluids spread evenly through the day (about 1.5–2 liters for most adults) help with this.
3. Keep clean, but do not overdo it. Rinsing with warm water is enough; lots of soap and scented toilet paper irritate the skin.
4. Do not self-treat. Pharmacy ointments, antibiotics or painkillers mask the symptoms but do not cure the disease.
5. Do not skip follow-up visits. Come in at the times your doctor recommends, both until the wound has fully closed and afterwards; if abscesses keep coming back, you will be checked for Crohn's disease and diabetes.

A child of about eight came to us at the end of a long journey. It had all started with intestinal worms: the worms led to constipation, the constipation to an anal fissure, the fissure to an anal abscess, and the abscess to an anal fistula. We started with conservative treatment, and after the tests we removed the fistula tract surgically. A week after the operation, the child was doing well and was not at all afraid of their doctor. Every patient's situation is different.