Anorectal disorders

anatomy

• Dentate line marks junction of rectum and anal canal
• Anal canal joins perianal skin at anal verge
• Proximal to dentate line, mucosa has 8-14 convoluted longitudinal folds: Canals of Morgagni
• Each column is connected to dentate line by flap of mucosa forming a 1-3mm deep anal crypt
• Anal sepsis, cryptitis, perianal abscesses and fistulas all form from inflammation, obstruction and infection of these crypts and glands
• Superior haemorrhoidal artery (from IMA) supplies proximal 2/3 of rectum
• Middle haemorrhoidal artery (from internal iliac a.) supplies distal 1/3 of rectum
• Inferior haemorrhoidal artery supplies the anus and rectum via submucosal network
• Venous and lymphatics mirrors arterial supply
• Superior rectal vein drains into portal system
• Middle rectal vein drains into IVC

anatomy

• Ischiorectal space
  • Lateral to external sphincters
• Pelvirectal space
  • Superior to levator ani
• Inferior mesenteric and para-aortic nodes drain the proximal 2/3 of rectum
• Inferior mesenteric nodes and internal iliac nodes drain distal 1/3 of rectum and proximal anal canal
• Inguinal nodes drain distal to dentate line
• Distal to dentate line somatic fibres are present
• Parasympathetic stimulation (S2-4) contracts the rectal wall and relaxes the internal sphincter
• Sympathetic stiimulation (L1-3) maintains continence through rectal wall relaxation and contraction of internal sphincter

Anal tags

• Skin tags are sometimes residuals of prior haemorrhoids
• Usually asymptomatic
• Inflammation can cause itching and pain
• Skin tags covering anal crypts, fistulas and fissures are called ‘sentinel tags’
• Surgical referral for excision of sentinel tags is warranted as IBD may be associated with these

Haemorrhoids

• Vascular cushions that become enlarged and distally displaced
• Seems to occur when supporting tissues of vascular cushions deteriorate
• Downward displacement of cushions leads to internal and external haemorrhoidal plexuses to become engorged
• Complications
  • Inflammation
  • Thrombosis
  • Prolapse
  • Ulceration
  • Ischaemia

haemorrhoids

• Internal haemorrhoids
  • Originate proximal to dentate line from terminal branches of superior rectal artery
  • Constant in their location, coursing longitudinally at 2-, 5- and 9-o’clock positions when viewed prone
  • Commonly single at 5 o’clock position
  • Not readily palpable and best visualised through anoscope
  • Appearance is consistent with columnar epithelial surface of surrounding anal canal
  • Viscerally innervated
• External haemorrhoids
  • Distal to dentate line and can arise anywhere due to dilatation of veins at anal verge
  • Can be seen on external inspection
  • Appearance consistent with stratified squamous epithelium of surrounding anoderm and exquisite sensory innervation

haemorrhoids

• Clinical features
  • Associated with constipation, prolonged straining at stool, frequent diarrhoea and older age
  • Consider IBD if frequent diarrhoea and haemorrhoids
  • Can develop during pregnancy
  • Increased portal pressure in chronic liver disease can produce marked dilatation and varix formation, distinct from true haemorrhoids, resulting in difficult to control bleeding
  • Tumors of the rectum and sigmoid colon with subsequent tenesmus, constipation and incomplete evacuation can lead to haemorrhoids
  • Haemorrhoids are the most common cause of bright rectal bleeding, however, tumors must be ruled out in any rectal bleeding >40yo
  • Ascites, ovarian tumors, distended bladders and excessive radiation-induced fibrosis can also lead to external haemorrhoids
  • Haemorrhoidal bleeding is usually limited, bright red on surface of stool, on toilet paper or noted at end of defecation dripping into bowl. If passing clots, suspect colonic lesion
  • Do not typically cause chronic slow blood loss and iron deficiency anaemia – rule out cancer

haemorrhoids

• Clinical
  • Do not typically cause pain unless thrombosed or strangulated fourth-degree internal haemorrhoids
  • If painful but not clinically thrombosed, suspect perianal or intersphincteric abscess or anal fissures
  • Thrombosed external haemorrhoids
    • Typically painful, burning perianal lumps with bluish-purple colour
  • Uncomplicated internal haemorrhoids
    • Painless due to visceral innervation
    • Anoscope reveals bulging, purple-coloured veins at distal rectum or anal canal
    • Often chief complaint is painless, bright-red rectal bleeding with defecation
  • Complicated internal haemorrhoids
    • May be palpable on digital exam if thrombosed or prolapsed
    • Non-reducible, prolapse internal haemorrhoids may become thrombosed and strangulated appearing dark red, with rectal bleeding and exquisite pain. Can then be complicated by ulceration, necrosis, gangrene, sepsis and hepatic abscess formation
    • Mucous discharge and pruritis ani may be seen with luminal prolapse

haemorrhoids

• Grades of internal haemorrhoids
  • Grade 1 – Luminal protrusion above dentate line – painless bleeding
  • Grade 2 – Prolapse with spontaneous reduction
  • Grade 3 – Prolapse requiring manual reduction
  • Grade 4 – Prolapse – non-reducible – leads to oedema and strangulation

haemorrhoids

• Treatment
  • General measures
    • Gentle drying of anus after baths to avoid perianal skin maceration
    • Topical analgesics and steroid-containing ointments may provide symptom relief
    • Avoid prolonged sitting on toilet
    • Bulk laxatives and stool softeners after acute phase has been treated
    • Avoid laxatives causing liquid stool as can lead to cryptitis and anal sepsis
    • High fiber, low-fat diet with increased water intake, regular exercise and avoidance of constipating agents should help prevention
    • Surgical referral for symptomatic haemorrhoids for consideration of procedural treatment
  • Both internal and external acutely thrombosed haemorrhoids may be treated with topical nifedipine and 1.5% lignocaine OR ISMN ointment with surgical follow-up

haemorrhoids

• Treatment
  • Internal haemorrhoids
    • Grade I and II – Warm baths for mild to moderately symptomatic 
    • Grade III – Manual reduction and warm baths 15 minutes TDS and after each bowel movement
    • Grade IV – Surgical consult in ED for continued and severe bleeding, pain, incarceration and/or strangulation

haemorrhoids

• Treatment
  • External haemorrhoids
    • Thrombosis is usually self-limited with resolution in 1 week
    • If thrombosis present >48 hours, swelling has begun to shrink, haemorrhoid is not tense, pain is tolerable can treat with warm baths and bulk laxatives
    • If thrombosis is <48 hours or extremely painful, clot excision can be of benefit
      • Should not be performed in ED on anyone with immunosuppression, children, pregnant women, portal hypertensoin, anticoagulated or coagulopathy
      • Local anaesthetic to skin overlying thrombosis
      • Elliptical incision distal to anal verge in overlying skin will expose thrombus, which can then be removed
      • Control bleeding by placing corner of gauze into wound and leave it there for a few hours
      • Small pressure dressing can be applied for 6-12 hours
      • F/u in 24-48 hours is recommended to ensure no complications arise and referral for definite haemorrhoidectomy
      • Do NOT incise (vs. excise) as incomplete clot evacuation leads to rebleeding, swelling and perianal skin tag formation

Anal fissures

• Superficial linear tear of anal canal below dentate line extending to the anal verge
• Acute = <6 weeks
• Chronic >6 weeks
  • Pale in colour with oedema of surrounding tissues
  • Persist due to severe, chronic, internal sphincter spasm +- secondary infection at base
  • Sentinel tag distally
  • Can form perianal or intersphincteric abscess if inflamed that may drain into the anal canal or posterior midline externally

Anal fissures

• Clinical features
  • Usually single and in midline posteriorly in 80-90% of cases
  • Anterior fissures seen in younger patients, female, obstetric trauma, occult external anal sphincter injury
  • Chronic non-healing ulcers, not in midline location should raise suspicion for more serious pathology e.g. Crohn’s, chronic UC, squamous cell carcinoma, adenocarcinoma of anal canal, Bowen’s disease, extramammary Paget’s disease, leukaemia, lymphoma, syphilitic fissures, chlamydia, gonorrhoea, HIV and tuberculous ulcer – Requires referral for biopsy and culture of anal canal

Anal fissures

• Fissures of Crohn’s are usually multiple, off midline and asymptomatic
• Consider child abuse
• Characterised by tearing pain with defecation and rectal bleeding
• May persist as dull ache and burning for hours after passing stool
• Subsides between bowel movements (helpful to differentiate from other pathology)
• Topical 2% lignocaine gel may allow digital rectal exam but sedation may be required
• If fissure visible and in posterior midline, can defer DRE until patient more comfortable at follow-up

Anal fissures

• Treatment
  • Usually heal over a few weeks but relapse is >50%
  • If doesn’t heal within 6 weeks or relapses are frequent – refer to surgeons
  • Warm baths for 15 minutes TDS/QID and after each bowel movement along with stool softeners
  • Fiber to diet to prevent stricture formation by promoting bulky stool
  • Topical lignocaine ointments and 1% hydrocortisone ointment may provide symptomatic relief
  • All medical therapies are as effective as placebo
  • For chronic fissures, all medical therapies are less effective than surgery

Anal stenosis

• Scarred fibrotic anal tissue
• May be congenital or secondary to haemorrhoidectomy, radiation, fistulectomy, trauma, IBD, chronic laxative use, STI and chronic diarrhoea
• PC – Constipation, bleeding, painful defecation and narrow-calibre stools
• Incontinence secondary to overflow constipation may occur
• May require specialist examination under sedation
• Treatment
  • Stool softeners, fiber and daily gradual anal dilatation after initial dilatation in OT
  • Stricturotomy and stricturoplasty are used if conservative measures fail

cryptitis

• Crypts lie between columns of Morgagni
• Flatten during passage of stool from puckered natural state
• Sphincter spasm and superficial trauma due to repeated diarrhoea or chronic constipation can cause breakdown of mucosa and inflammation
• Inflammation can then extend to the lymphoid tissue of crypts and anal glands
• PC – Anal pain, spasm, itchying +- bleeding
• Crypts most often involved are in posterior half of ana ring and in posterior midline (like anal fissures)
• Diagnosis requires anoscopy
• Treatment
  • Bulk laxatives, fiber, warm baths
  • Referral to surgeon if infection has progressed and there is deep, redundant crypt that will not drain on its own
  • May lead to development of fissure-in-ano, fistula-in-ano and perirectal abscess

Fistula-in-ano

• May result from drainage of anorectal abscess or be associated with UC, Crohn’s, colonic malignancy, radiation, leukaemia, STI, actinomycosis, anal fissures, foreign bodies to TB
• Originates from infected crypt and tracks to the skin
• Characterised as:
  • Submucosal
  • Intersphincteric
  • Suprasphincteric
  • Transsphincteric
  • Extrasphincteric
  • Goodsall’s rule can help determine the location of the internal opening
    • Anterior-opening fistulas tend to follow a straight path while posterior-opening fistulas may folllow a curving path including horseshoe-shaped

Fistula-in-ano

Fistula-in-ano

Fistula-in-ano

• Clinical features
  • Open tracts may produce painless, blood-stained mucous, anal itching and malodourous discharge
  • If tract blocked can lead to inflammation and spontaneous rupture OR abscess formation
  • Abscess formation presents as throbbing, constant pain, worse with sitting, moving and defecation
  • Induration or fibrous cords palpable at anal region suggest chronic fistula
  • Openings at anal margin suggest superficial connection from intersphincteric region
  • Openings proximal to anal margin suggests deeper, more superior abscess
  • Trans-anal USS more accurate than CT (82% vs. 24%) and equal to MRI in evaluation of fistulas
• Treatment
  • Analgesics, IV fluids, Cipro +Metronidazole + Antipyretics
  • Surgical referral
  • Definitive treatment may involve placing drain in fistula, fibrin glue, fistulotomy, fistulectomy or more complex procedures

Anorectal abscess

• Almost all start with anal cryptitis and gland inflammation
• Typically aerobic and anaerobic polymicrobial infections including S. aureus, Streptococcus, Enterococcus, E. coli, Proteus and Bacteroids
• Can involve perianal, submucosal, intersphincteric, ischiorectal, post-anal (connection between ischiorectal spaces either side) and supralevator spaces
  • Perianal most common
  • Supralevator least common
• Other conditions associated:
  • Crohn’s disease, carcinoma, trauma, Hodgkin’s lymphoma, TB, UC, gonococcal proctitis, radiation fibrosis, Chlamydia, Actinomyces, herpes, lymphogranuloma venereum and immunocompromise

Anorectal abscess

• Clinical features
  • Most common in young to middle-aged males
  • May have no systemic features or if deeper may have fever, oedema, anorexia
  • Pain described as dull, thrombbing pain that is worse immediately before defecation and improves afterwards but persists between bowel movements (unlike anal fissures)
  • Perianal abscess
    • Close to anal verge, posterior midline usually with superficial tender mass +- fluctuance
    • Easily palpable at anal verge
    • Usually no systemic features vs. peri-rectal
  • Perirectal (includes all below)
    • May only be palpable through rectal wall or more lateral to anal verge on buttocks
  • Ischiorectal abscess
    • Larger, indurated, well-circumscribed and more lateral to anal verge
  • Post-anal
    • May not have cutaneous signs but rectal pain and tenderness are invariably present

Anorectal abscess

• Intersphincteric
  • Pain often considerably worse with straining/coughing/defecation
  • May be associated with rectal discharge and fever and often found in posterior midline on palpation
• Supralevator abscess
  • Often an extension of intersphincteric abscess with few outward signs
  • Generalised, non-distinct perirectal pain with fever, malaise, leukocytosis and urinary retention
  • Tender inguinal lymphadenopathy may be the only clue
  • May be palpable on vaginal examination
• Investigation
  • If unsure, transanal USS can be very helpful
  • If suspicious of deep abscess, CT +- MRI can differentiate

Anorectal abscess

• Treatment
  • All perirectal abscesses need drainage in theatre
  • If perirectal, immunosuppressed, systemically unwell, elderly, valvular heart disease, diabetic, cellulitis given PipTaz and obtain surgical consult for all
  • Simple, isolated, perianal abscesses may be drained in ED under local or procedural sedation
  • US can delineate size and depth
  • Drainage with linear or cruciate incision over abscess and then gauze packing to prevent closure
  • Cover wound with bulky dressing and advise frequent warm baths
  • Antibiotics are not necessary in healthy patients
  • ED follow-up in 24 hours and surgical referral for definitive care

Proctitis

• Presents as anorectal pain, itching, discharge, ulcers, diarrhoea, bleeding or lower abdo cramping
• Causes include prior radiation, autoimmune disorders, vasculitis, ischaemia and enteric bugs and gonorrhoea/chlamydia/treponema pallidum + HSV2, HIV, HPV
• If suspected STI, screen for all and treat empirically – bacterial MCS/viral PCR/syphilis serology

Proctitis – condylomata acuminata

• Anal warts HPV types 6 and 11
• Small dot-like lesions to larger papilliform lesions with subsequent pain, itching, bleeding and discharge
• Often assocaited with vulvovaginal and penile lesions
• Treatments include local cryo/laser/cautery or surgical excision
• Anorectal carcinoma and cervical/orogrenital cancer can result

Proctitis – gonorrhoea

• Most women and 50% of men with anogenital gonorrhoea are asymptomatic
• Classically present as tenesmus, yellow/bloody discharge 1 week after exposure
• Infection is not isolated to posterior crypts (unlike non-STI cryptitis)
• Dissemination to heart, liver, CNS and joints can occur
• Screen and treat empirically

Proctitis – chlamydia

• Lymphogranulomatous variety – Serovars L1,2,3
  • Mostly in the tropics
  • Can involve rectum by perirectal lymphatic invasion from vaginal seeding or direct anorectal infection
• Non-lymphogranulomatous variety – Serovars D-K
  • Does not cause the extensive rectal scarring or stricturing than lymphogranulomatous disease does
• May be asymptomatic through to pruritis, pain, bleeding, tenesmus and discharge
• More severe disease may cause fever, flu-like sympotms and prominent unilateral lymph node enlargement
• Perirectal abscess and chronic fistulas can form
• Screen and treat empirically
  • Doxycycline 100mg BD for 21 days or erythromycin 500mg QID for 21 days

Proctitis – syphilis

• Primary syphilis – Chancres at anal verge within weeks of infection
  • May be misdiagnosed as a simple fissure as very painful
  • May have symmetric lesion on other side and inguinal adenopathy
• Secondary syphilis
  • Condylomata lata – Flat, large, raised, grey-white lesions in perianal region
• Screen with rapid plasma reagin and VDRL tests with confirmation of disease with T. pallidum-specific immunoassay
• Empirical treatment with Benzathine penicillin 2.5 million units IM stat OR doxycycline 100mg PO BD for 14 days

Proctitis – HSV

• Anorectal herpes usually HSV-2
• Symptoms occur within weeks with itching and soreness through to severe pain
• Small, discrete vesicles on erythematous base through to large, coalesced, rupturing vesicles
• Can cause severe constipation and difficulty urinating due to pain
• Can develop flulike illness and inguinal lymphadenopathy
• Symptoms last several weeks with recurrence
• Viral PCR and treat with analgesia, stool softeners and acyclovir 400mg five times daily for 10 days then 400mg TDS for 5 days for recurrence
• Prophylactic dose is acyclovir 400mg BD
• Consider HSV, syphilis, HIV, chancroid and donovanosis when anal ulcers are present

Proctitis – hiv-related infections

• Severe rectal pain, haematochezia and diarrhoea are common presenting complaints
• Obtain serology for syphilis and take swabs
• Common causative agents are HSV ½, Mycobacteria avium-intracellulare, CMV, Salmonella, Shigella, Campylobacter, Entamoeba, Cryptosporidium, Isospora and Giardia

Proctitis – radiation

• Acute radiation proctocolitis
  • Presents as tenesmus, diarrhoea, bleeding within 6 months of radiotherapy to area
  • Seen in 50-70% of patients undergoing radiation therapy to pelvis
  • Mostly self-limiting but 10% go on to suffer chronic radiation proctocolitis
• Chronic
  • Can occur up to 30 years following radiation therapy
  • Presents like acute or with complications such as strictures, ulcerations, constipation, obstruction, perforation or fistulas
  • Can be difficult to differentiate from infectious/IBD
  • Stool softeners and sulfasalazine are mainstays of therapy

Rectal prolapse

• Three types
  • Rectal mucosa only
  • All layers (complete)
  • Intussusception of upper rectum into and through the lower rectum so that mucosal apex of intussusception nearly extends to the anus (incomplete)
• In children is usually males <3yo and mucosal only
  • Rarely protrudes >5cm beyond anal margin
• Clinical features
  • Partial prolapse can result in stool seepage or constipation
  • In more advanced cases, can notice mass after defecation/strenuous straining or just with mobilisation
  • Irritation to mucosa occurs with discharge and bleeding
  • Pain is not usually a significant feature
  • Concentric folds vs. radial folds with prolapsed internal haemorrhoids

Rectal prolapse

• Treatment
  • In young children
    • Analgesia then can reduce manually by spreading buttocks and gently replacing protruding mucosa with slow steady pressure
    • Refer for further evaluation due to possible underlying cystic fibrosis, polyps, pelvic floor weakness, diarrhoea and malnutrition
  • In adults
    • Complete prolapsed rectum can have manual reduction attempted
    • Gentle rolling motion with thumbs in medial part and fingers on lateral part, pushing thumbs in first and rolling fingers towards middle
    • Obtain surgical consult for repair
    • If rectal walls oedematous, manual reduction can be impossible
      • Can apply liberal granulated sugar over the prolapsed segment to reduce oedema and re-attempt reduction
      • Gaue with lubricant can be placed at anal verge after reduction and taped in place for a few hours
    • If cannot be reduced, is severe or recurs after reduction, or if ischaemia/gangrene is suspected, obtain emergent surgical consult

Anorectal tumors

• Risk factors – Smoking, anal intercourse, HIV, HPV (16 and 18)
• Transition zone between stratified squamous and columnar epithelium of rectum is the region where a variety of carcinomas can arise
• Anal canal neoplasms
  • Those proximal to the dentate line including the transition zone
  • Far more virulent, metastasise early and poor prognosis
  • SCC of anal canal much worse prognosis than anal margin SCC
  • Metastasise to perirectal, mesenteric and paravertebral lymph nodes via portal circulation
  • Third most common site of malignant melanoma (after skin and eye) and may not be pigmented and is frequently missed
  • Adenocarcinoma of glands and ducts, transitional cell carcinoma, melanoma, SCC, Kaposi’s, villous adenoma
• Anal margin neoplasms
  • Distal to dentate line and much lower malignant potential, slow to metastasise (except melanoma)
  • Metastasise to femoral and inguinal nodes
  • Bowen’s disease, SCC, basal cell carcinoma, Melanoma, Paget’s disease

Anorectal tumors

• Clinical features
  • Asymptomatic, pruritis, pain and bleeding admixed with stool, rectal fullness
  • Later anorexia, bloating, weight loss, diarrhoea, constipation, narrowed calibre of stool and tenesmus
  • Later perirectal abscess, fistulas and bloody mucous discharge
  • Villous adenomas often produce watery diarrhoea and profuse rectal discharge with secondary excoriation and pruritis
  • Anal margin neoplasms tend to be circumferential presenting as bleeding, persistent ulcers or chronic dermatological conditions
  • Any ulcer that fails to improve within 30 days or any discrete skin lesions that fails to improve with appropriate therapy must be biopsied
  • If uncertain, must refer for proctoscopic/sigmoidoscopic examination

Rectal foreign bodies

• Perforation below the peritoneal reflection can cause retroperitoneal free air seen along psoas muscles. Can sometimes be managed conservatively.
• Perforation above the peritoneal reflection causes intraperitoneal free air. Surgical emergency.
• Treatment
  • Surgical removal usually necessary
  • If attempting to remove in ED, consider likelihood of injury and obtain post-removal X-rays/proctoscopic examination or at least 12 hours of observation afterwards
  • Large bulbar objects produce a vacuum effect, which can be overcome by passing a 20-26Fr catheter beyond the object and injecting 30mL of air
  • Consider PipTaz cover if considerable manipulation (risk of bacteraemia), ischaemia or perforation

Pruritis ani

• May be idiopathic
• Second most common anorectal condition after haemorrhoids
• 1-5% of population and men 4x more likely to suffer
• Usually 4^th to 6^th decades of life
• Clinical features
  • Symptoms usually worse at night
  • Skin becomes macerated by constant mucous and prurulent discharge

Pruritis ani

• Causes
  • Staph, strep and STI can all cause pruritis
  • Pinworms common in children and institutionalised adults
  • Candida albicans in diabetics is commonly isolated but rarely causes pruritis but Trichophyton species do cause pruritis
  • Frequent irritation from loose bowel movements, diarrhoea and poor anal hygiene
  • Excessive anal cleansing and tight synthetic underwear can cause pruritis
  • Anal margin neoplasms can present with pruritis +- any other anorectal disease (e.g. abscess, fissures, haemorrhoids, prolapse
  • Systemic conditions: Diabetes, psoriasis, pemphigus, leukaemia, lymphoma, thyroid disorders, hepatic diseases, renal failure, iron deficiency anaemia, Vitamin A, D, niacin deficiency
  • Lumbosacral radiculopathy
  • Dietary: Caffeine, cola, calcium, chocolate, citrus, alcohol, tomatoes, spices, peanuts
  • Bed bugs, lice, scabies
  • Dermatological: Atopic dermatitis, lichen planus, psoriasis, seborrhoic dermatitis
  • Crohn’s disease

Pruritis ani

• Treatment
  • Diagnose and treat any underlying cause
  • Perianal streptococcal dermatitis should be looked for in children and adults
  • Idiopathic cases – Fiber diet, gloves at bedtime, warm baths 15 minutes 2-3 times per day, avoid soap, thoroughly dry, zinc oxide to protect and promote healing, athlete’s foot powder can enhance drying
  • 1% hydrocortisone for allergic component of inflammation
  • Refer to proctologist or dermatologist for persistent symptoms

Pilonidal sinus

• Foreign body granuloma reaction to ingrown hair perpetuated by presence of hair and repeated bouts of infection
• Mostly people under 40, usually obese, hirsute men
• 20-40% recurrence rate
• Occur in midline in upper part of natal cleft
• Sometimes mistakenly diagnosed as perirectal abscesses
• May be secondary openings laterally, they do not communicate with the anorectum
• Long horse-shoe type fistulas from perianal abscess may drain close to pilonidal sinus but do not open into midline
• Consider anal fistulas, syphilitic and tuberculous granulomas, simple furuncles, fungal infections and sacral osteomyelitis
• Carcinoma is a rare complication
• Treatment
  • Incision and drainage + antibiotics if cellulitis is present
  • Refer to surgeon for definitive care

Hydradenitis suppurativa

• Perineal disease more common in males (vs. axillae for women)
• Fistulas with malodorous discharge develop but do not extend to the intersphincteric plane
• Fistulas that extend above the dentate line may suggest co-existing cryptoglandular or Crohn’s disease
• Treatment is with drainage of any small abscesses and surgical referral
• Topical clindamycin or oral clindamycin + rifampin can be helpful
• For advanced disease, resection of skin and subcutaneous fat down to fascia yields the lowest recurrence rate

Rectovaginal fistula

• Flatulence or malodorous vaginal discharge +- gross stool fro vagina
• Air or stool in urine
• Rectal urine
• CT scan and surgical referral in ED

Last Updated on October 28, 2020 by Andrew Crofton