Anal leakage is a fistula formed when the rectum or anal canal communicates with the surrounding skin, also known as anal leakage. The disease can occur in all ages and genders, but it is more common in adults and can also occur in infants and children. The incidence is about 10% to 20% of anorectal diseases. There is usually a history of recurrent perianal abscesses with a history of self-rupture or incision and drainage.
It is usually composed of primary internal orifice, fistula and secondary external orifice, but there are also cases with only internal or external orifice. The fistula can pass through the internal and external sphincter and anal levator muscle into the rectum and perianal space. In a few cases, anorectal leaks also develop from the collapse of perirectal abscesses complicated by other diseases. Most anal leaks are the sequelae of anal canker sores. Clinically, it can be classified as tuberculous and septic in terms of the type of infecting bacteria. It is characterized by recurrent localized pus flow, pain, and itching as the main symptoms, and a fistula leading to the rectum can be palpated or probed.
According to Western medicine, anal leakage and perianal abscess belong to two pathological stages of purulent infection in the perianal space, respectively, perianal abscess in the acute stage and anal leakage in the chronic stage.
1.Clinical manifestations
(1) Symptoms
(1) Discharge: there is intermittent or persistent flow of pus in the anus, which does not close for a long time. In the initial stage, there is more pus flowing, with fecal odor, yellow and thick; in a longer period of time, the pus is gradually reduced, thin and light like water, or sometimes not, with intermittent pus flowing; if it is too tired, the pus increases, and sometimes there can be fecal outflow; if the pus has been less and suddenly increases, and there is pain in the anal part, it often indicates an acute infection or the formation of a new branch.
Pain: When the fistula is open, there is usually no pain and only a feeling of swelling at the anal opening. If the external opening is temporarily closed and pus accumulates, local pain can occur and can be accompanied by fever, chills and other systemic symptoms; after the external opening is broken and pus flows out, the symptoms can be rapidly reduced or disappear. Sometimes the pain can be caused by the large inner mouth and the inflow of feces into the duct, especially when the pain increases during defecation.
③Itching: itching is caused by constant impregnation of the skin around the anus with pus, and sometimes it can be accompanied by perianal eczema.
Systemic symptoms: Generally, there are no systemic symptoms. In case of perianal abscess, there may be symptoms such as malignant cold and fever. Complicated anal leakage with recurrent attacks and prolonged flow of pus and blood may lead to physical wasting and mental depression. If tuberculous anal leakage is often accompanied by active tuberculosis lesions, there are symptoms such as flushing of the cheeks and low fever.
(2) Physical signs
Visual examination: the external orifice is visible, and those with a small raised external orifice are mostly septic; those with a large, depressed external orifice, dark purple surrounding skin, and subcutaneous subcutaneous submerged cavity should be considered complex or tuberculous anal leakage. Sometimes when pressing the leaky canal, purulent secretions may spill out from the external opening. Checking the amount, thickness or thinness, color, odor and patency of the pus has certain differential diagnostic significance for the nature and degree of anal leakage.
Palpation: The depth and direction of the anal leak can be understood by touch and the location of the internal opening can be determined. Stiff cords can be palpated under the skin of the perianal area in low anal leakage, but not easily in high or tuberculous cases. The hard nodules or depressions near the dentate line can be palpated by finger palpation, which are mostly the location of the internal orifice.
2.Disease classification
Clinically, anal leakage is generally classified into the following two categories.
Simple anal leakage refers to a single external opening of the paranal skin. If there is only an external opening without an internal opening, it is called an external anal leak, also called an external blind leak; if there is only an internal opening connected to the fistula without an external opening, it is called an internal anal leak, also called an internal blind leak.
Complex anal leak is called horseshoe anal leak if there are more than three openings inside or outside the anus; or if the canal penetrates more than two gaps; or if there are many canals and the canal is branched across the anus; or if the canal is shaped like a horseshoe around the anus.
The diagnosis is usually made with a history of anal canker and physical signs such as external orifice, ducts and internal orifice of the lesion. The most important part of the diagnosis of anal leakage is to understand the location and number of internal orifices, the relationship between the canal and the anal sphincter, the nature and extent of the lesion, the function of the anal sphincter and the systemic condition, in order to make a correct diagnosis and guide the treatment.
3.Transfer and prognosis
(1) Most anal leaks can be cured after surgical treatment.
(2)For high complex anal leakage, those with unclear intraoperative internal opening and more branches, there may be a possibility of non-healing wound or recurrence.
4.Treatment
The treatment of anal leakage is generally divided into non-surgical treatment and surgical treatment. Non-surgical treatment is mainly used to control the infection, reduce symptoms and control the development, but it cannot be completely cured or relatively cured for a while, but it is easy to relapse.
Surgical treatment is aimed at removing the infected anal glands and removing the infected foreign body from the fistula, which is the key to treatment. However, for the violation of the anal sphincter function, especially for the anal leakage where the lesion involves the rectal ring of the anal canal, it must be treated correctly in order to avoid the sequelae such as anal incontinence.
5.Surgical treatment
This disease is mainly treated by surgery. All fistulas are cut open, and if necessary, the scar tissue around the fistula can be trimmed appropriately so that it drains smoothly and the wound gradually heals. The key to success or failure of surgery is to find the correct internal opening and to cut or remove it, otherwise the wound will not heal, and even if it heals temporarily, it will recur over time. At present, the commonly used surgical treatment, there are hanging wire therapy, incision therapy, incision and hanging wire combination, etc.
6, prevention and conditioning
(1) Keep the anus clean and develop good hygiene habits.
(2)If perianal abscess is found, early incision and drainage of pus is advisable, and one incision can avoid the formation of anal leakage.
(3) Patients with anal leakage should be treated early to avoid the accumulation of pus and poor drainage caused by blockage of the external opening, which may trigger new branches.
(4) Postoperative bleeding should be prevented, and careful and conscientious dressing changes are advisable to prevent pseudo-adhesion of the wound (bridge healing) and non-healing of anal leakage.