Fistulas: Seeking Clarity in Surgical Diagnosis

Differentiation of Fistulas

Hello Dr.
Ke, in mid-June, I developed a cyst between my anus and scrotum, so I went to a nearby surgical clinic for drainage.
After about a week with a dressing, it healed.
However, three to four days later, it swelled up again, and I returned to the same surgical clinic for drainage.
This time, only a small amount of dark blood and a larger volume of regular blood was drained, and it healed after about three days.
About four to five days later, the affected area swelled up again, appearing like a hematoma.
It ruptured on its own in the morning, and I immediately went to a major hospital for treatment.
The doctor only asked if it was a recurrent issue and if I had not received any treatment for several years, then diagnosed it as a fistula and advised me to schedule surgery.
They placed a dressing on the area and asked me to sit for 15 minutes to stop the bleeding before I left.
That evening, feeling doubtful, I went to a nearby proctology clinic for a second opinion and recounted the previous events.
The doctor performed a digital rectal examination and informed me that there was no opening inside the anus, suggesting it was likely a sebaceous cyst rather than a fistula, and recommended anti-inflammatory treatment followed by surgical excision.
I was given antibiotics and ointment before returning home.
Now, I am unsure which doctor to trust and whether I should proceed with surgery for a fistula.

Tou Xian, 40~49 year old female. Ask Date: 2019/07/02

Dr. Ke Fangxu reply Surgery

The distinction between a fistula and a sebaceous cyst can only be confirmed through a physical examination.
If the condition is still in the acute inflammatory phase, it may be difficult to ascertain, as both the fistula and the internal opening may not be clearly visible at this time.
If there are concerns, it is advisable to start a course of oral antibiotics for a period of time.
Once the inflammation subsides, a thorough examination can be conducted to obtain a definitive diagnosis, after which a decision regarding surgery can be made without delay.

Reply Date: 2019/07/02

More Info

Understanding the situation you are facing regarding the diagnosis of a possible fistula or a different condition is crucial for your health and peace of mind. Based on your description, it seems you have been experiencing recurrent issues in the area between your anus and scrotum, which has led to multiple drainage procedures and conflicting medical opinions.

First, let's clarify what a fistula is. A fistula is an abnormal connection between two body parts, often resulting from an infection or inflammation. In the context of the anal region, an anal fistula typically connects the anal canal to the skin near the anus, often resulting from an abscess. Symptoms can include pain, swelling, and discharge, which seems to align with your experiences.

Your initial visits to the surgical clinic resulted in drainage of what was suspected to be an abscess, which is a common treatment for such conditions. However, the recurrence of swelling and the nature of the fluid drained (black blood and regular blood) suggest that there may be an underlying issue that has not been fully addressed. The fact that the area has swollen again after drainage indicates that the source of the problem may not have been completely resolved, which raises the suspicion of a fistula or another type of cyst, such as a sebaceous cyst or a pilonidal cyst.

The conflicting opinions from the two doctors you consulted can be confusing. The first doctor suspected a fistula based on your history of recurrent issues, while the second doctor, after performing a digital examination and using an anoscope, suggested that there was no opening in the anal canal, indicating that it might be a sebaceous cyst instead. This discrepancy highlights the complexity of diagnosing conditions in this region, as both conditions can present similarly but require different treatment approaches.

In terms of treatment, if a fistula is confirmed, surgical intervention is typically necessary to prevent further complications and to promote healing. On the other hand, if it is a cyst, the treatment may involve excision, especially if it is recurrent or symptomatic. The antibiotics and topical ointment prescribed by the second doctor suggest an attempt to manage any infection or inflammation, which is a reasonable approach before considering surgical options.

Given the conflicting diagnoses, it would be prudent to seek a third opinion, preferably from a colorectal surgeon who specializes in conditions of the anal and rectal area. They can perform a thorough examination, possibly including imaging studies like an MRI or ultrasound, to better visualize the area and determine the exact nature of the problem. This will help clarify whether you are dealing with a fistula, a cyst, or another condition entirely.

In summary, while it is understandable to feel uncertain about which diagnosis to trust, it is essential to gather more information and possibly seek a specialist's opinion. This will ensure that you receive the most appropriate treatment for your condition, whether it requires surgical intervention or conservative management. Remember, your health and well-being are paramount, and getting a clear diagnosis is the first step toward effective treatment.

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