Survey on Anal Fistula in Dhaka Medical College

Hospital, Dhaka.

A DISSERATION SUBMITTED TO THE DEPARTMENT OF

PHARMACY, DAFFODIL INTERNATIONAL UNIVERSITY IN THE
PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF BACHELOR OF PHARMACY.

i
Internal Examiner-1

Internal Examiner-2

External Examiner

ii
Submitted by

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iv
 Dedication
This paper is dedicated to my parents, supervisor, friend, and all individuals who have contributed
to it in any way, regardless of the scale of their contribution.

v
Abstract
Anal fistula is a common condition where abnormal passages form between the anal canal and
surrounding tissue. Infection, especially abscess formation, is a major cause of this condition.
Traditional treatments like fistulotomy or fistulectomy are effective but can result in fecal
incontinence if the muscles are involved. To prevent incontinence, sphincter-preserving techniques
like Seton drainage, fibrin sealant closure, and ligation of the intersphincteric fistula tract (LIFT)
have been suggested. However, these methods have different success rates and may require
multiple surgeries. Recurrent anal fistulas are even more challenging and are often associated with
a higher risk of recurrence and fecal incontinence. It is important to use imaging techniques like
endoanal ultrasonography and MRI to thoroughly assess the condition and plan treatment. While
conventional surgical options are still common, newer techniques like LIFT and anal fistula plugs
aim to minimize damage to the sphincter and preserve function. Despite promising results, there
are still challenges to overcome, particularly when it comes to long-term effectiveness and
recurrence rates. However, a comprehensive understanding of fistula anatomy and treatment
options is essential for improving patient outcomes and reducing treatment failures. This survey
aims to clarify the causes, prevalence, and treatment options for anal fistula. Additionally, it aims
to improve knowledge of potential postoperative issues after anal fistula surgeries and offers
solutions.

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 Content

Chapter Topic Page No.

1 Introduction 01-02
1 1.1 Diagnosis 02
1.2 Types of Anal Fistula 02
1.3 Treatments for an anal fistula 03
1.4 Post-Operative Complication of Anal Fistula 03
1.5 Prevalence of Anal Fistula 04
2 2.1 Literature review 05-06
3 3.1 Purpose of the study 07-08
4 4.1 Methodology 09-10
5 5.1 Result & Discussion 11-22
6 6.1 Conclusion 23-24
7 7.1 Reference 25-27

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 List of Table

Serial No. Name of the Table Page No.

1 Gender 13
2 Age 13
3 Diagnosis test 16
4 Other common diseases that patients may 18
have
5 Treatments taking for anal fistula 18
6 Surgical procedures patients use to treat anal 19
fistula

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 List of Figure

Serial No. Name of the Figure Page No

1 Pie chart of gender 13
2 Pie chart of age 14
3 Pie chart of how long has the patient been 14
living with an anal fistula?
4 Bar Chart of symptoms of anal fistula 15
5 Pie chart of pain associated with your anal 15
fistula
6 Pie chart of Diagnosis test 16
7 Column chart of familiar with anal fistula 17
8 Pie chart of Diagnosis test 17
9 Pie chart of Treatments taking for anal fistula 18
10 Pie chart of Planning for surgery 19
11 Pie chart of surgical procedures patient uses 20
to treat anal fistula
12 Pie chart of condition of fistula after surgery 20
13 Pie chart of effects of anal fistula on work 21
and career
14 Pie chart of effects of anal fistula on mental 21
health and emotional well-being
15 Bar chart of effects of treatment cost 22

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1
1 Introduction
An anal fistula is a small tunnel that forms between the end of the bowel and the skin near the
anus, resulting from an infection near the anus and the subsequent development of a pus-filled
abscess.(1) This condition can lead to discomfort, skin irritation, and does not typically resolve on
its own.(2) Surgery is often recommended for treatment. Anal fistulas commonly originate from
infected anal glands, and if left untreated, they may lead to recurrent abscesses and potential
systemic infections.(3) Factors such as colitis, peri anal abscess, chronic diarrhea, inflammatory
conditions such as crohn’s disease, diverticulitis, anal STIs (sexually transmitted infections), anus
affected by tuberculosis, surgical complication near the anus and radiation treatment for rectal
cancer can increase the risk of anal fistula development.(4,5) Surgical intervention is considered
essential to allow drainage, prevent infection, and relieve symptoms, although repair of the fistula
itself is often an elective procedure chosen by patients because of the associated discomfort and
inconvenience.(3)

1.1 Diagnosis
Healthcare providers employ various methods to diagnose anal fistulas, aiming to identify both
external and internal openings. A physical exam is commonly conducted, with the possibility of
utilizing a fistula probe or anoscope to explore the affected area. In cases where the external
opening is closed or the inside source is challenging to access without causing discomfort,
procedures may be performed under anesthesia. An anoscope or proctoscope, equipped with a
lighted scope, can be employed for a thorough examination, and hydrogen peroxide injection may
reveal the infection's source by creating bubbles.(6,7)
Specialists, particularly those focused on colon and rectal diseases, may be consulted if symptoms
suggest an anal fistula. During the examination, the doctor may apply pressure to assess soreness
and check for pus discharge. Diagnostic tools such as fistula probes, anoscopy, and imaging studies
like ultrasound or MRI contribute to a comprehensive diagnosis.(8) Procedures may occur in
outpatient settings or during Examination Under Anesthesia (EUA), allowing for exploration with
a fistula probe or other instruments.(9)
Ultimately, the diagnosis involves a combination of physical examination, specialized scopes,
imaging techniques and others.(10) Collaboration between healthcare providers, including
gastrosurgeons, surgical gastroenterologists, or general surgeons, is often crucial for an accurate
and comprehensive assessment of anal fistulas.(11,12)

1.2 Types of Anal Fistula

Healthcare providers categorize anal fistulas based on their positioning relative to the anal
sphincter muscles, crucial for bowel movement control and preservation. These classifications
include: intersphincteric, transsphincteric, suprasphincteric, extrasphincteric, and superficial anal
fistulas.(13)
Intersphincteric fistulas pass through the internal sphincter muscle and emerge near the anus, but
transsphincteric fistulas penetrate both layers of the anal sphincter muscles before opening away

2
from the anus, frequently generating several external openings known as "horseshoe fistulas."
Suprasphincteric fistulas wrap around the external sphincter after passing through the internal
sphincter, then stretch upward and cross the puborectalis muscle. Extrasphincteric fistulas, which
originate in the rectum rather than the anus, circumvent both sphincter muscles and may affect
surrounding tissues. Superficial anal fistulas, which bypass the sphincter muscles, often begin
below the anal gland and travel through the surrounding skin. Additionally, submucosal fistulas,
while less common, remain superficial beneath the submucosa and do not cross either sphincter
muscles.(13,14)

1.3 Treatments for an anal fistula

Anal fistulas are complex conditions that often require surgical intervention for effective treatment.
The approach to surgery varies depending on the type and severity of the fistula. For simple
fistulas, which involve minimal muscle and no branches, a fistulotomy is typically performed. This
procedure involves cutting open the fistula to allow it to heal from the bottom up. However, there
is a risk of damaging the anal sphincter muscles, which can lead to bowel control issues.(15,16)
Complex fistulas, on the other hand, may require more intricate procedures. Seton procedures
involve placing a surgical thread called a seton in the fistula tract to aid drainage and promote
healing. This method is particularly useful for fistulas that involve a significant amount of muscle
or have branches. Endorectal advancement flap and LIFT procedures are alternatives that aim to
preserve sphincter function while treating the fistula. These techniques involve either using healthy
tissue to cover the fistula opening or closing off the intersphincteric tract to promote
healing.(14,17)
In recent years, there have been advancements in surgical techniques for anal fistulas, including
the use of fibrin glue injection, fistula plugs, fistula laser closure and VAAFT (video-assisted anal
fistula treatment). These methods offer minimally invasive options with varying success rates,
providing alternatives for patients who may not be suitable candidates for traditional surgery or
who wish to avoid the potential risks of sphincter damage.(14,17)

1.4 Post-Operative Complication of Anal Fistula

Anal fistula surgery can lead to various complications, including infection, abscess formation,
fistula recurrence, fecal incontinence, fistula tract damage, delayed wound healing, chronic pain,
anal stenosis, urinary retention, and rectovaginal fistula. Infection can cause increased pain,
swelling, redness, and discharge from the surgical site. Abscess formation can cause severe pain
and may require further drainage or treatment. Fistula recurrence may occur due to incomplete
removal or complications during the healing process. Fecal incontinence can occur due to damage
to the anal sphincter muscles. Delayed wound healing may occur in individuals with underlying
health conditions or behaviors that impair healing. Chronic pain at the surgical site may persist
even after initial healing. Anal stenosis can result from scar tissue formation or excessive healing,
causing difficulty with bowel movements and discomfort. (18,19)

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1.5 Prevalence of Anal Fistula
Anal fistula prevention involves various measures such as proper hygiene, dietary changes,
hydration, and avoiding straining. Early recognition and treatment of anal abscesses are crucial.
Lifestyle modifications like maintaining a fiber-rich diet, staying hydrated, and avoiding excessive
alcohol and caffeine intake are essential. Regular exercise and managing underlying conditions
like Crohn's disease can also help prevent complications. Over-the-counter medications and home
remedies like warm water soaks and sitz baths can provide relief. Avoiding painkillers and
maintaining good personal hygiene are key. To prevent recurrence, maintain a balanced diet, drink
plenty of water, and strengthen the immune system. Practice healthy bowel habits to reduce strain
on the anal canal. Overall, incorporating these strategies into daily life can significantly reduce the
risk of developing anal fistulas.(20,21)

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 Chapter-2
LITERATURE REVIEW

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2.1 Literature Review
A literature search was conducted on anal fistula using Google Scholar, PubMed, and other
databases to uncover relevant information. This search focused on anal fistula, including its causes,
diagnosis, treatments, prevalence, and post-operative complications. After reviewing the available
literature, 12 papers were chosen as the most informative and recent. A comprehensive review of
these manuscripts was conducted.

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3.1 Purpose of study:
The purpose of this project is to comprehensively investigate the prevalence, treatment and post-
operative complications of patients suffering from anal fistula in Dhaka Medical College
Hospital. By gathering detailed information from individuals who have experienced or are
currently living with anal fistulas, this study aims to achieve the following objectives:
➢ Prevalence assessment.
➢ To evaluate the various management strategies and treatment of anal fistula, including
medication, dietary changes and other medical procedures.
➢ Post-operative complication of anal fistula.
➢ To create awareness among the people about anal fistula.

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 Chapter-4
METHODOLOGY

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4.1 Methodology
The study conducted an initial manuscript review and conducted an online and physical survey
on Anal Fistula in Dhaka Medical College Hospital, Dhaka.
Inclusion Criteria: Anal fistula patients provided data for this investigation. and observed their
lifestyles, as well as what may be predicted if they lead more likely lives. Additionally, the kind
of medications patients were taking and if they had any additional illnesses were observed.
Date collection strategy:
❖ I personally visited Dhaka Medical College Hospital to carry out this survey. I gathered
information from patients, took advice from medical professionals, and used Google
forms to summarize all the data.
The survey took place at Dhaka Medical College Hospital from January 15 to January 21,
2024. Over 200 people participated, with 120 being male and 80 females.

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5.1 Result and Discussion
The questions on Prevalence, Treatment, and Post-Operative Complications of Patients Suffering
from Anal Fistula in Bangladesh were:
❖ How long have you been living with an anal fistula?
Less than 6 months 6 months to 1 year 1-5 years More than 5 years
❖ What symptoms have you experienced due to your anal fistula?
Persistent anal pain
Swelling and redness around the anus
Discharge of pus or blood
Itching and irritation around the anus
Other (please specify)
❖ How would you describe the pain associated with your anal fistula on a daily basis?
Mild Moderate Severe I don't experience pain
❖ What diagnostic methods did you use to diagnose anal fistula?
Digital Rectal Examination Proctoscopy Colonoscopy MRI/CT Other
❖ How familiar were you with anal fistulas before being diagnosed?
Very familiar Somewhat familiar Not familiar at all
❖ How comfortable are you discussing your anal fistula symptoms with healthcare providers?
Very comfortable Comfortable Neutral Uncomfortable Very uncomfortable
❖ Do you have any other diseases?

❖ What types of treatments are you taking now for your anal fistula?
Medications Surgical treatment Lifestyle modifications Other
❖ Are you planning for surgery?
❖ What surgical procedures did you use to treat your anal fistula?
Fistulotomy Fistulectomy Seton placement Fibrin plug and glue Endorectal
advancement flap Other
❖ Condition of fistula after surgery? Total cure Recurrent facing issues
❖ What non-medical treatments or home remedies have you tried for managing anal fistula
symptoms?
❖ How has anal fistula impacted your work or career?
Not at all Mildly Moderately Severely
❖ How has anal fistula affected your mental health and emotional well-being?
Not at all Mildly Moderately Severely
❖ How much does the treatment cost?

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❖ Gender
Number of patients Percentage (%)
(N=200)
Male 120 60
Female 80 40
Table-1: Gender

During this investigation, it was found that 60% of the patients were male, representing the
majority of the data, with the remaining 40% being female. It can now be concluded that males
are more susceptible to anal fistulas than females. This is attributed to females being generally
more attentive to personal hygiene than males, which in turn makes them less prone to this
condition.

Figure-1: Pie chart of gender

❖ Age

Age Number of patient (N=200) Percentage (%)

20-29 35 17
30-39 52 26
40-49 69 34
50-59 25 13
60-69 19 10

Table-2: Age

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This study explored the impact of age on the development of anal fistulas. The lowest percentage
was noted in the 60–69 age group (10%), with the highest proportion found in the 40–49 age group
(34%). This indicates that individuals are more prone to develop anal fistulas between the ages of
40- 49. The second-highest incidence occurred in the 30–39 age group, at 26%. This could be
attributed to the tendency of patients aged 30 to 50 to seek medical attention earlier than younger
individuals, potentially elucidating the higher incidence in this age bracket.

10% 17%
13%

26%
34%

20-29 30-39 40-49 50-59 60-69

Figure-2: Pie chart of age

❖ How long has the patient been living with an anal fistula?

Figure-3: Pie chart of how long has the patient been living with an anal fistula?

It can be observed that 44% of individuals suffering from anal fistula have had the condition for
more than 5 years. Following this group, 30% of patients have been dealing with anal fistula for 1
to 5 years. The smallest percentage, only 10%, consists of patients experiencing anal fistula for
less than 6 months. This indicates that patients may not initially prioritize seeking treatment for
anal fistula during the first 6 months.

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❖ Symptoms of anal fistula

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other
24

84
Itching and irritation around the anus
168

92
Discharge of pus/blood
184

86
Swelling and redness around the anus
172
92
Persistent anal pain
184

0 20 40 60 80 100 120 140 160 180 200

Percentage (%) Number of patient (N=200)

Figure-4: Bar Chart of symptoms of anal fistula

Common symptoms of an anal fistula include peristaltic anal pain, discharge of pus or blood,
swelling and redness around the anus, itching and irritation around the anus and others. This study
shows that about 92 percent of patients have persistent anal pain and discharge of pus or blood,
making it the most common symptom. Then, 86 percent of patient experience swelling and redness
around the anus, placing it in the second position. 84 percent of patient report itching and irritation
around the anus, while some patients do not experience these symptoms, but most of them do.
Other symptoms include fever, pain when urinating, and difficulty holding stool in.

❖ Pain associated with your anal fistula

Figure-5: Pie chart of pain associated with your anal fistula

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Here we can observe that the majority of patients experience pain due to anal fistula, which varies
from severe to mild. Among these patients, 46 percent describe their pain as severe, 30 percent as
moderate, and 20 percent as mild. Only 4 percent of patients report not feeling pain but
experiencing other symptoms. These patients have had an anal fistula for less than six months.

❖ Diagnosis test
Test Name Number of patient (N=200) Percentage (%)
Physical/Rectal Examination 36 18%
Fistula probe 56 28%
Colonoscopy 88 44%
MRI/CT 16 08%
Other 04 02%

Table-3: Diagnosis test

In this study on anal fistula, various diagnostic tests were utilized. Among them, colonoscopy
emerged as the most common choice among doctors, with 44 percent of patients undergoing this
procedure, making it the most frequently used diagnostic tool. Colonoscopy is primarily employed
for simple fistulas. The second most common diagnostic test was the fistula probe, used by 28
percent of patients. This technique is particularly valuable for identifying the fistula tract and is
commonly used for complex fistulas. MRI/CT scans are also considered effective diagnostic
methods for anal fistulas, with 8 percent of patients undergoing these tests. This diagnostic
approach can help reduce the recurrence of anal fistulas, which is a common post-operative
complication. Physical examination remains a fundamental diagnostic method for anal fistulas,
involving an assessment of the area surrounding the anus.

Figure-6: Pie chart of Diagnosis test

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❖ Familiar with anal fistula

120
104
100

80

60 52 52
44
40 26
22
20

0
Very familiar Somewhat familiar Not familiar at all

Number of patient (N=200) Percentage (%)

Figure-7: Column chart of familiar with anal fistula

It is evident that a majority of patients, constituting 52 percent, were unfamiliar with anal
fistulas. 26 percent of patients possessed limited knowledge about this condition. This lack of
awareness significantly contributes to treatment delays among patients. It is concerning that
only 22 percent of patients are familiar with anal fistulas, which is deemed unacceptable.
Education and the elevation of social awareness are crucial in preventing the formation of anal
fistulas.

❖ Discussing this issue with a healthcare provider.

Figure-8: Pie chart of Diagnosis test

It has been noted that a significant portion of patients, approximately 42 percent, experience
considerable uncomfortable when broaching the topic of anal fistulas with healthcare providers,
particularly female professionals. Merely 10 percent of patients feel at ease engaging in such
discussions. This unease frequently results in delays in seeking necessary medical attention for
anal fistula-related concerns, ultimately resulting in the deterioration of the patient's health and the
exacerbation of the problem. Furthermore, 14% of patients indicated a neutral stance on this
matter.

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❖ Other common diseases that patients may have
Colitis Peri anal Chronic Crohn’s Diverticulitis Anal STIs
abscess diarrhea disease (sexually
transmitted
infections)

Table-4: Other common diseases that patients may have

It has been noted that individuals diagnosed with Crohn's disease and perianal abscess have a
higher susceptibility to developing anal fistulas compared to those without these conditions.
Additionally, diseases such as colitis, chronic diarrhea, diverticulitis, and sexually transmitted
infections (STIs) affecting the anal region can also contribute to the occurrence of anal fistulas.

❖ Treatments taking for anal fistula

Treatment Number of patients Percentage (%)
Medications 176 88%
Surgical treatment 172 86%
Lifestyle modifications 172 86%

Table-5: Other common diseases that patients may have

Here, it can be observed that all patients are receiving treatment for an anal fistula, which includes
medication, lifestyle modifications, and surgery. Among these patients, 88 percent are currently
undergoing medication treatment, placing them in the majority. The medication primarily consists
of antibiotics, with pain relief prescriptions typically lasting for 10 days. Additionally, 86 percent
have already undergone surgical procedures, with the remaining patients preparing for it. Lifestyle
modifications are also integral to the treatment regimen, aiding in lowering the chances of anal
fistula recurrence. Ultimately, a combination of these treatment approaches is utilized to treat anal
fistulas.

86
Lifestyle modifications
172

86
Surgical treatment
172
88
Medications
176

0 20 40 60 80 100 120 140 160 180 200

Percentage (%) Number of patients

Figure-9: Pie chart of Treatments taking for anal fistula

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❖ Planning for surgery

Figure-10: Pie chart of Planning for surgery

The pie chart shows the number of patients planning for surgery. The majority of patients, 84
percent, are planning for surgery. Therefore, it can be said that surgery is the preferred treatment
option. The remaining patients are awaiting the surgeon's decision.

❖ Most common medicine patient taking for anal fistula

• A-Flox 500mg • Napa 500mg
• Fluclox 500mg • Beuflox 500mg
• Flubex 500mg • Floxabid 500mg
• Phylophen 500mg • Filmet 400mg
• Adecin 500mg • Flagyl 400mg
• Aporacin 500mg • Pactorin Retard 2.6mg

❖ The non-medical treatments or home remedies patients use

• Bactrocin ointment
• Povisep solution for hip-bath
• Combination of Povisep + Hexiscrub solutions for hip-bath.
• Lifestyle change

❖ Surgical procedures patients uses to treat anal fistula

Surgical procedure Number of patient (N=200) Percentage (%)
Fistulotomy 67 33
Fistulectomy 29 14
Seton placement 45 23
Fibrin plug and glue 35 18
Endorectal advancement flap 24 12

Table-6: Surgical procedures patients use to treat anal fistula

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Most patients choose a fistulotomy procedure as their primary surgical treatment, with
approximately 33 percent of patients choosing this option. Fistulotomy is recognized as the most
common and effective surgical procedure for treating anal fistulas. Seton placement is the second
most popular choice, with about 23 percent of patients undergoing this procedure. Seton placement
is particularly effective for complex anal fistulas. The least common choice is the endorectal
advancement flap, selected by only 12 percent of patients.

12% Fistulotomy

Fistulectomy
33%
18% Seton placement

Fibrin plug and glue

Endorectal advancement flap

23% 14%

Figure-11: Pie chart of surgical procedures patient uses to treat anal fistula

❖ Condition of fistula after surgery

Figure-12: Pie chart of condition of fistula after surgery

This pie chart shows that 64.6 percent of patients were completely cured after surgery, while 35.4
percent of patients experienced a recurrence of anal fistula. Recurrent anal fistula is the most
common postoperative complication for patients with anal fistula. This is due to a lack of
maintaining personal hygiene or a failure in the surgical procedure.

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❖ Effects of anal fistula on work and career.

Figure-13: Pie chart of effects of anal fistula on work and career

The chart indicates that 44 percent of patients are mildly affected by anal fistula in their work or
career, 26 percent are moderately affected, and 16 percent are severely affected. Only 14 percent
of patients reported that they are not affected at all by anal fistula.

❖ Effects of anal fistula on mental health and emotional well-being

Figure-14: Pie chart of effects of anal fistula on mental health and emotional well-being

Here we observe that 38 percent of patients indicate mild mental and emotional impact from anal
fistula, representing the highest percentage. Following closely, 28 percent of patients report a
moderate impact, the second-highest percentage. Merely 10 percent of patients assert being
unaffected by the condition.

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❖ Treatment cost

55,000-60,000 28.60%

50,000-55,000 18.60%

45,000-50,000 23.60%

40,000-45,000 12.60%

35,000-40,000 10.60%

30,000-35,000 6%

0% 5% 10% 15% 20% 25% 30% 35%

Percentage (%)

Figure-15: Bar chart of effects of treatment cost

The chart shows that the majority of patient treatment costs ranged from 55,000 to 60,000 tk, which
is the highest percentage at 28.6 percent. The next most common range is 45,000-50,000 tk,
accounting for 23.60 percent. The patient cost range of 50,000 to 55,000 tk represents 18.60
percent. Only 6 percent of patients have treatment costs between 30,000-35,000 tk, placing it at
the lowest position. Although the cost depends on the patient's health condition, it is observed that
the cost normally does not exceed 60,000 tk.

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6.1 Conclusion

In conclusion, managing anal fistulas presents significant challenges due to the lack of consensus
on optimal treatment methods and the risks of recurrence and incontinence. The current knowledge
lacks level Ⅰ evidence, shows inconsistent results, and varies in surgical techniques. Recurrent anal
fistulas pose even greater challenges, with higher rates of re-recurrence and potential compromise
of continence.

Successful management requires a thorough understanding of anorectal anatomy, fistula

pathoanatomy, and patient selection. Various treatment options exist, such as fistulotomy,
advancement flap, LIFT and others, but no universally accepted method has emerged due to
diverse outcomes and patient demographics. Patient selection and sepsis control are crucial for
improving healing rates.

Further research is necessary to address the ongoing dilemma of balancing the risks of
incontinence with the chances of cure, especially in patients with recurrent disease or urgency.
Additionally, well-controlled trials are needed to accurately assess and understand the
effectiveness of different treatment options. Ultimately, the optimal procedure should be
customized to the individual patient, considering the specific characteristics of their fistula.

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7.1 Reference

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