Fistula or Anal Fissure: Your Symptoms and Diagnosis

Anal fistula or fissure?

Hello Dr.
Ke, over two years ago, I felt a swelling sensation near my coccyx, and sometimes I experienced sharp pain in my anus.
I went to Hsinchu Mackay Memorial Hospital to see a colorectal surgeon, who noted a hard area near my coccyx that was somewhat painful upon pressure.
I asked him what it was, and he said it could potentially develop into a fistula in the future, but there was no fistula present at that time (an anal examination was performed).
He mentioned that surgery would be necessary if a fistula developed.
The anal pain was attributed to a slight fissure, which did not involve bleeding.
After that, I didn't follow up for a while.
Three months ago, I returned to Mackay for a follow-up, and the doctor used a tube (an anoscope?) for about ten seconds.
I asked if it was a fistula, and he said he did not find any.
I mentioned that I occasionally experience sharp pain, and he reiterated that it was likely due to a fissure, possibly caused by occasional constipation.
He prescribed some medication for me to apply.
Recently, I feel okay, with occasional sharp pain that has become less frequent.
I would like to ask the doctor if an anoscope can determine the presence of a fistula.
So, am I only dealing with a fissure? I am a bit worried about the possibility of a fistula, as surgery would seem quite troublesome...
I am concerned about misdiagnosis causing delays (I have seen online that some people have been misdiagnosed).
Thank you, doctor.

Eric, 20~29 year old female. Ask Date: 2012/03/13

Dr. Ke Fangxu reply Surgery

The most accurate method for examining anal fistulas is digital rectal examination, as it allows for precise palpation of the fistula's course and opening.
Not all high-tech diagnostic methods are necessarily more accurate.
Chronic anal fissures may lead to the formation of superficial fistulas due to the healing of the epithelium.
The absence of a fistula currently does not guarantee that one will not develop in the future.
It is important to maintain good bowel habits, and if any abnormal symptoms occur, a follow-up visit to the hospital is essential for early detection of any changes in the condition.

Reply Date: 2012/03/13

More Info

Fistulas and anal fissures are two distinct conditions that can cause discomfort and pain in the anal region, and understanding their differences is crucial for proper diagnosis and treatment. Based on your description, it seems you have been experiencing symptoms that could be related to an anal fissure, which is a small tear in the lining of the anus, often caused by trauma from passing hard stools or constipation.

Understanding Anal Fissures
Anal fissures are characterized by sharp pain during bowel movements, which may be accompanied by a small amount of bleeding. The pain can be intense and may persist for some time after the bowel movement. In your case, the intermittent pain you experience could be attributed to a fissure, especially if it is related to episodes of constipation.

Fistulas: What Are They?
On the other hand, an anal fistula is an abnormal connection between the anal canal and the skin surrounding the anus. Fistulas often develop as a result of an infection in the anal glands, leading to the formation of an abscess. Symptoms of a fistula may include persistent drainage of pus or blood, swelling, and pain around the anus, especially during bowel movements.

Diagnostic Procedures
Regarding your concerns about the diagnostic procedures, an anal examination, including the use of an anoscope (the "管子插進去" you mentioned), is a common method for evaluating the anal region. This procedure allows the physician to visualize the anal canal and rectum, helping to identify any abnormalities such as fissures or signs of a fistula.
While an anoscopy is effective in diagnosing anal fissures, it may not always detect a fistula, especially if it is not actively draining or if it is located deeper within the tissue. If there is a suspicion of a fistula, additional imaging studies such as an MRI or a fistulogram may be recommended to provide a clearer picture of the anatomy and any potential connections.

Treatment Options
For anal fissures, treatment typically involves conservative measures such as dietary changes to include more fiber, increased fluid intake, and the use of stool softeners to prevent constipation. Topical treatments, such as nitroglycerin ointment or calcium channel blockers, may also be prescribed to promote healing and relieve pain.
If a fistula is confirmed, surgical intervention is often necessary to repair the abnormal connection. The type of surgery will depend on the complexity of the fistula and its location.

Conclusion
In summary, based on your symptoms and the evaluations you have undergone, it appears that you may be dealing with an anal fissure rather than a fistula, especially since no fistula was identified during your examinations. However, if your symptoms persist or worsen, it is important to follow up with your healthcare provider for further evaluation. They may recommend additional diagnostic tests if there is any doubt about the presence of a fistula.
It’s understandable to feel anxious about the possibility of surgery, but many cases of anal fissures can be managed effectively with conservative treatment. Always communicate openly with your healthcare provider about your concerns and symptoms to ensure you receive the best care possible.

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