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Journal of
Coloproctology
www.jcol.org.br

1 Original Article

2 Incidence of fistula after management of perianal

3 abscess

4 Q1 Riyadh Mohamad Hasan

5 University of Baghdad, Al-Kindy College of Medicine, Department of Surgery, Baghdad, Iraq
6

7 a r t i c l e i n f o a b s t r a c t
8

9 Article history: Background: Perianal fistula is among the most common anorectal diseases encountered
10 Received 2 May 2016 in adults, men are more prone to be affected than women. There is a close relationship
11 Accepted 15 May 2016 of abscess and fistula in etiology, anatomy, pathophysiology, therapy, complications and
12 Available online xxx morbidity, it is appropriate to consider them as one entity.
13 Aim of study: To determine the incidence of fistula formation and recurrent abscess in a
14 Keywords: sample of Iraqi patients in Baghdad and decide whether primary fistulotomy should be
15 Fistula performed at the time of incision and drainage of perianal abscesses.
16 Perianal Patients and methods: A retrospective study of 68 patients with perianal abscess operations
17 Abscess conducted in Baghdad. They underwent incision and drainage under either local or general
anesthesia at Al-Kindy Teaching Hospitals and private hospitals over a 15-year period from
January 2000 to December 2015. Their ages ranged from 20 to 68 years (40.21 ± 1.34) males
(63/68) (92.64%) were more than females (5/68) (7.35%). Patients were treated with incision
over the abscess under anesthesia and drainage of the abscess was done. The patients were
followed up for an average 18 months (range 12–24 months) after abscess drainage or until
a fistula appeared and abscess recurrence.
Results: The study group comprised of 68 (92.64%) patients with perianal abscess with a
median age 39 years (range 20–68 years). The mean follow-up period was identified to be 18
months (range 12–24 months). Males (63/68) (92.64%) were more than females (5/68) (7.35%).
The incidence of fistula formation after follow up, the patients with perianal abscess after
incision and drainage was 31/68 (45.58%) and males (30/31) (44.11%) were more than females
(1/31) (1.47%). The most common site was posterior then left lateral position. The percent-
age of patients with recurrent abscess n = 6 (8.82%)were lower than fistula formation n = 31
(45.58%). The percentage of males n = 4/6 (5.88%) were more than females 2/6 (2.94%).
Conclusions: The incidence of anal fistula in a sample of Iraqi patients with perianal abscess
was 45.58% and percentage of recurrence of perianal abscess was 8.82%. To avoid division of

E-mail: riyadhmoh57@gmail.com
http://dx.doi.org/10.1016/j.jcol.2016.05.002
2237-9363/© 2016 Sociedade Brasileira de Coloproctologia. Published by Elsevier Editora Ltda. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Hasan RM. Incidence of fistula after management of perianal abscess. J Coloproctol (Rio J). 2016.
http://dx.doi.org/10.1016/j.jcol.2016.05.002 JCOL 178 1–4
 JCOL 178 1–4
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anal sphincter muscle, secondary fistulotomy is advised to be done later when anal fistula
will be formed.
© 2016 Sociedade Brasileira de Coloproctologia. Published by Elsevier Editora Ltda. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

Incidência de fistulas em seguida ao tratamento de abscesso perianal

18 r e s u m o
19

20 Palavras-chave: Experiência: A fistula perianal está entre as mais comuns doenças anorretais observadas em
21 Fístula adultos; os homens demonstram maior tendência para serem afetados, em comparação
22 Perianal com as mulheres. Existe íntima relação entre abscessos e fistulas em termos e etiologia,
23 Abscesso anatomia, fisiopatologia, tratamento, complicações e morbidade; assim, é cabível considerá-
24 los como uma mesma entidade.
25 Objetivo do estudo: Determinar a incidência de formação de fístulas e de abscesso recorrente
26 em uma amostra de pacientes iraquianos em Bagdá, e decidir se a fistulotomia primária deve
27 ser realizada por ocasião da incisão e drenagem de abscessos perianais. Pacientes e méto-
28 dos: Estudo retrospectivo de 68 pacientes com operações para abscesso perianal realizadas
29 em Bagdá. Foi realizada incisão e drenagem sob anestesia local ou geral no Hospital-Escola
30 Al-Kindy e em hospitais privados ao longo de um período de 15 anos, de janeiro de 2000 até
31 dezembro de 2015. As idades variavam de 20 a 68 (40,21 ± 1,34) anos. Havia maior número de
32 homens (63/68) (92,64%) do que de mulheres (5/68)(7,35%). Os pacientes tiveram o abscesso
33 tratado sob anestesia, e foi realizada a drenagem do abscesso. Os pacientes foram moni-
34 torados, em média, durante 18 meses (variação, 12-24 meses) após a drenagem do abscesso,
35 ou até o surgimento de uma fístula e recorrência do abscesso.
36 Resultados: O grupo de estudo compreendeu 68 (92,64%) pacientes com abscesso perianal,
37 com idade mediana de 39 anos (variação, 20-68 anos). O período médio de seguimento foi de
38 18 meses (variação, 12-24 meses). Havia maior número de homens (63/68) (92,64%) versus
39 mulheres (5/68) (7,35%). No seguimento, a incidência de formação de fístula nos pacientes
40 com abscesso perianal após a incisão e drenagem foi de 31/68 (45,58%), e os homens foram
41 mais afetados (30/31) (44,11%) versus mulheres (1/31) (1,47%). O local mais comum foi a
42 posição posterior e, em seguida, a lateral esquerda. O percentual de pacientes com abscesso
43 recorrente (6, 8,82%) foi mais baixo do que o percentual para pacientes com formação de
44 fístula (31, 45,58%). O percentual de homens (4/6, 5,88%) foi maior versus mulheres (2/6,
45 2,94%).
46 Conclusões: A incidência de fístula anal em uma amostra de pacientes iraquianos com
47 abscesso perianal foi de 45,58% e o percentual de recorrência de abscesso perianal foi de
48 8,82%. Para evitar a divisão do músculo esfinctérico anal, é aconselhável fazer uma fistulo-
49 tomia secundária mais tarde, quando a fístula anal já estiver formada.
© 2016 Sociedade Brasileira de Coloproctologia. Publicado por Elsevier Editora Ltda. Este
é um artigo Open Access sob uma licença CC BY-NC-ND (http://creativecommons.org/
50 licenses/by-nc-nd/4.0/).

perianal abscess from outset or as a later sign in 26–37% of the 63

Introduction time.5–7 After drainage the abscess, probe the corresponding 64

anal crypt gently, looking for a fistula in ano. Primary fistulo- 65

51 Fistula is among the most common anorectal diseases
tomy may be attempted when it is identified and superficial.8 66
52 encountered in adults, Men are more prone to be affected
About 1000 primary fistulotomies were done during drainage 67
53 than women.1 There is a close relationship of abscess and
of an abscess with no adverse results.9 One can suspect devel- 68
54 fistula in etiology, anatomy, pathophysiology, therapy, com-
opment of fistula later on when there is a prolonged drainage 69
55 plications and morbidity, it is appropriate to consider them as
from an incision site beyond 2–3 months and abscess heals 70
56 one entity.2 A previous history of perianal abscess can usually
and recurs at the same first location.10 Abscess recurrence and 71
57 be mentioned and drained either spontaneously or surgically
later on fistula formation is due to insufficient drainage and 72
58 under local or general anesthesia, thus a fistula-in-ano rep-
late onset drainage.11–13 The incidence of fistula following an 73
59 resents the chronic phase of ongoing perianal abscess.3 It is a
abscess incision and drainage was 26% and incidence of recur- 74
60 common disease with an incidence of about 2 cases per 10,000
rent abscess was 37%.14,15 The anal canal should be searched 75
61 population per year and likely to occur between the ages of
properly at the time of drainage and probe the anal crypt 76
62 30 and 50 years.4 Fistula in ano are either associated with
gently looking for fistula. If a fistula is identified and is quite 77

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http://dx.doi.org/10.1016/j.jcol.2016.05.002 JCOL 178 1–4
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Table 1 – Incidence of fistula in ano and recurrent abscess after follow-up patients with perianal abscess.
Patients with perianal abscess, n = 68

Cure Fistula formation Recurrent abscess

n = 31 (45.58%) n = 31 (45.58%) n = 6 (8.82%)

Males Females Males Females Males Female

n (%) n (%) n (%) n (%) n (%) n (%)

29 (42.64) 2 (2.94) 30 (44.11) 1 (1.47) 4 (5.88) 2 (2.94)

Initial sites

Site Males Females Males Females Males Females

n (%) n (%) n (%) n (%) n (%) n (%)

1. Posterior 11 (35.48) 5 (16.12) 16 (51.61) 3 (9.67) 4 (66.66) 2 (33.33)

2. Right lateral 5 (16.12) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
3. Left lateral 10 (32.25) 0 (0) 12 (38.70) 0 (0) 0 (0) 0 (0)

78 superficial, primary fistulotomy may be attempted using a Statistical analysis was done using MINITAB statistical soft- 117

79 loose seton of braided, nonabsorbable suture that inserted into ware 13.20. 118

80 the fistula tract, tied loosely to act as a drain. This is termed a

81 “primary” or “synchronous” fistulotomy which is curative and Results
82 avoid the need for subsequent fistula surgery.8,10 On the other
83 hand, about two thirds of perianal abscesses never progress The study group comprised of 68 (92.64%) patients with peri- 119

84 to fistulas and that a primary fistulotomy with its possible anal abscess with a median age of 39 years (range 20–68 years). 120

85 complications is usually unnecessary and the patients who The mean follow-up period was identified to be 18 months 121

86 are ideal candidates for primary fistulotomy are also the eas- (range 12–24 months). Males (63/68) (92.64%) were more than 122

87 iest to treat with delayed fistulotomy with subsequent low females (5/68) (7.35%). All of them had a perianal abscess 123

88 morbidity.3 Thus, the prudent rule would be to defer fistulo- managed by incision and drainage under anesthesia. Their 124

89 tomy until the fistula becomes obvious. duration of hospital stay was 1–2 days. 125

90 The aim of this study was to assess the incidence of anal The incidence of fistula formation after following up the 126

91 fistula and recurrent abscess after incision and drainage of patients operated for perianal abscess was 31/68 (45.58%) and 127

92 perianal abscess in a sample of Iraqi patients in Baghdad and males (30/31) (44.11%) were more than females (1/31) (1.47%). 128

93 decide whether primary fistulotomy should be performed at The most common site was posterior then left lateral position 129

94 the time of incision and drainage of anorectal abscesses. as shown in Table 1. The percentage of patients with recurrent 130

abscess n = 6 (8.82%)were lower than fistula formation n = 31 131

(45.58%). The percentage of males n = 4/6 (5.88%) were more 132

Patients and methods than females 2/6 (2.94%). The most common site was also pos- 133

terior to anus. The percentage of cured patients, 31/68 (45.58%) 134

95 A retrospective study of 68 patients operated upon for peri- was similar to percentage of patients who developed fistula, 135

96 anal abscess conducted in Baghdad. They underwent incision 31/68 (45.58%). Males were representing the higher percentage 136

97 and drainage under either local or general anesthesia at Al- 42.64% than females 2.94%. posterior abscess represents the 137

98 Kindy Teaching Hospitals and private Hospitals over a 15-year common site 35.48% followed by left lateral 32.25% and lastly 138

99 period from January 2000 to December 2015. Their ages ranged the right lateral 16.12%. 139

100 from 20 to 68 years (40.21 ± 1.34) males (63/68) (92.64%) were

101 more than females (5/68) (7.35%). The inclusion criteria were Discussion
102 adults aged 18 years and above who presented with perianal
103 abscess, while the exclusion criteria were patients under eigh- Abscess and fistula in ano are common cryptoglandular 140

104 teen years, abscess with known fistula, complicated abscesses disease16 which is most common in people aged between 141

105 (multiple or bilateral abscess), Crohn’s disease, immunosup- 20 and 50 years with four-fold male predominance and an 142

106 pression, malignancy, necrotizing fasciitis and disseminated annual incidence of 1 in 10,000.17 That is in agreement with 143

107 tuberculosis. The Scientific and Ethical Committee of Al-Kindy our results, males were (63/68) (92.64%) that is more than 144

108 Medical College and Hospitals had approved the study. Writ- females (5/68) (7.35%). Their median age was 39 years. Abscess 145

109 ten informed consents were obtained from the patients with after incision and drainage may manifests later on as fis- 146

110 perianal abscesses. tula in ano and recurrent abscess that require repeat surgical 147

111 Patients were treated with incision over the abscess under drainage. Thus, treating fistula at the same time may reduce 148

112 anesthesia (local or general) that allows thorough examina- the late squeal but this could affect the function of the anal 149

113 tion and drainage of the abscess and opening all loculi was sphincter in some patients who may not have later devel- 150

114 done. The patients were followed up for an average 18 months oped a fistula-in-ano.18 Our study showed that incidence of 151

115 (range, 12–24 months) after abscess drainage or until a fistula fistula in ano was 31/68 (45.58%) and males (30/31) (44.11%) 152

116 appeared and abscess recurrence. were more than females (1/31) (1.47%). The most common site 153

Please cite this article in press as: Hasan RM. Incidence of fistula after management of perianal abscess. J Coloproctol (Rio J). 2016.
http://dx.doi.org/10.1016/j.jcol.2016.05.002 JCOL 178 1–4
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4 j coloproctol (rio j). 2 0 1 6;x x x(x x):xxx–xxx

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Please cite this article in press as: Hasan RM. Incidence of fistula after management of perianal abscess. J Coloproctol (Rio J). 2016.
http://dx.doi.org/10.1016/j.jcol.2016.05.002 JCOL 178 1–4