How to Differentiate Between Anal Fistula and Folliculitis?

Is it an anal fistula or folliculitis?

I apologize for the inconvenience, but I would like to inquire about something.
About six months ago, I developed a lump on my buttocks, and at that time, I underwent incision and drainage.
It healed, but the wound turned into a small depression that occasionally oozes pus and blood.
There is a ring of tissue around the wound that feels firm, while the center is soft.
I visited the colorectal department at Chang Gung Memorial Hospital in Taipei, where the doctor performed a digital rectal examination and stated that it was not a fistula, and that my small opening is quite far from the anus.

After two or three months, since I was still experiencing occasional pus discharge, I returned to Shin Kong Hospital for a follow-up.
The doctor there also said it was not a fistula, but rather an inflamed tissue, similar to folliculitis, and recommended surgery, which would require an appointment and could take about 15 minutes.

Yesterday, I went to see another doctor at Shin Kong Hospital.
He used a needle to insert into the area but did not perform a digital rectal examination.
He diagnosed it as an anal fistula.
I told him that the previous doctors had said it was not a fistula, so I was confused about the change in diagnosis.
He kept saying it would be complicated because it is located further from the anus, which raises concerns that the fistula may have a complex course, making surgery more difficult.

Additionally, I was informed that the bacteria involved is Escherichia coli.
I am quite confused about what is happening.
I was given ointment and medication, but it seems like they are hesitant to perform surgery.
After three visits, how can I determine whether it is folliculitis or a fistula?

janice, 20~29 year old female. Ask Date: 2011/07/14

Dr. Yu Mingchang reply Surgery

Hello^^ Based on the symptoms you described, along with the digital rectal examinations performed by the first two physicians, the likelihood of folliculitis is higher.
If it is indeed folliculitis and you are experiencing recurrent episodes, you will need to undergo debridement surgery to clean out the repeatedly inflamed areas to prevent future recurrences.
If your issue is a fistula, it is even more important to perform a fistulotomy to avoid future recurrences.

Reply Date: 2011/07/14

More Info

Differentiating between an anal fistula and folliculitis can indeed be challenging, especially when symptoms overlap and the clinical presentation is not straightforward. Based on the information you've provided, let's break down the characteristics of both conditions and discuss how they can be distinguished.

Anal Fistula
An anal fistula is an abnormal connection between the anal canal and the skin surrounding the anus. It often develops as a result of an infection in the anal glands, leading to an abscess. Here are some key features of anal fistulas:
1. Symptoms: Patients typically experience persistent drainage of pus or blood from the opening near the anus, pain, swelling, and sometimes fever. The drainage may be intermittent or continuous.

2. Physical Examination: A thorough examination, including digital rectal examination, is crucial. An anal fistula may be identified by the presence of an external opening, which may be tender and may have surrounding inflammation. The fistula tract can sometimes be traced with a probe.

3. Location: The position of the external opening in relation to the anal sphincter is important. Fistulas can be classified as intersphincteric, transsphincteric, suprasphincteric, or extrasphincteric based on their location.

4. Imaging Studies: In some cases, imaging studies such as an MRI or an endoanal ultrasound may be necessary to visualize the fistula tract and assess its complexity.

Folliculitis
Folliculitis, on the other hand, is an inflammation of the hair follicles, often caused by bacterial infection, irritation, or blockage. Here are the distinguishing features:
1. Symptoms: Folliculitis typically presents as small, red bumps or pustules around hair follicles, which may be itchy or tender. It usually does not cause significant drainage unless there is a secondary infection.

2. Physical Examination: The affected area may show signs of inflammation, such as redness and swelling, but it is usually localized to the hair follicles without the formation of a tract leading to the skin.

3. Location: Folliculitis can occur anywhere on the body where hair follicles are present, including the anal area, but it is generally not associated with the formation of a fistula.

4. Response to Treatment: Folliculitis often responds to topical antibiotics or antiseptics, and symptoms may resolve with proper hygiene and care.

Your Situation
Given your description of a small pit that occasionally drains pus and blood, along with the presence of soft tissue around it, it is understandable that there is confusion regarding the diagnosis. The fact that different doctors have provided varying opinions adds to the complexity.

1. Previous Assessments: It is important to consider the assessments made by the specialists you consulted. If they performed a thorough examination and ruled out a fistula, it may suggest that your condition is more consistent with folliculitis or another inflammatory process.

2. Persistent Symptoms: The ongoing drainage and the presence of soft tissue suggest that there may be an underlying issue that needs to be addressed. If the drainage is consistent and the area remains inflamed, it may warrant further investigation.

3. Need for Surgical Evaluation: If there is still uncertainty, seeking a surgical consultation may be beneficial. A colorectal surgeon can provide a more definitive evaluation and may recommend imaging studies or a minor surgical procedure to clarify the diagnosis.

Conclusion
In summary, differentiating between an anal fistula and folliculitis requires careful clinical evaluation, including a detailed history, physical examination, and possibly imaging studies. Given the complexity of your case, it may be worthwhile to seek a second opinion from a colorectal surgeon who specializes in anal disorders. They can provide a comprehensive assessment and discuss the best management options for your condition.

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