A Simple guide to Anal Fistula

A Simple guide to Anal Fistula
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What is Anal Fistula?
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Anal Fistula (or fistula-in-ano) is a chronic granulous track which communicate between the anorectal canal and the perianal skin.

There may be several external openings but only one internal opening

What is the cause of Anal Fistula?
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Anal Fistula usually result from :
1.breakdown of anorectal abscesses

2.follows surgery for anal fissure

3.Less common causes are:
lymphogranuloma

carcinoma of rectum

ulcerative colitis,

regional ileitis

tuberculosis

What are the symptoms of Anal Fistula?
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1.pain especially on sitting down

2.purulent painless discharge(pus) near the anus

3.Recurrent perianal abscesses(pockets of pus around the anus)

4.pruritis ani(itch in anus)

How are Anal Fistula diagnosed?
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1.thorough examination of the perianal region

2.Rectal examination and palpation of the fistula track

3.Pass a probe through the perianal opening to determine the length of the track

4.Sigmoidoscopy and colonoscopy to detect internal opening and other lesions in the rectum and large intestine

5.Barium enema to exclude any ulcerative colitis and regional ileitis


What is the treatment of Anal Fistula?
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There are 2 types of anal fistula:
1.High level fistulas penetrate the levator ani-muscle of the anal sphlinter

2.Low level fistulas are below the levator ani and are more common.

Treatment of lowlevel fistula:
1.lay open the track and curette(scrape the lining and debris in the track out)

Treatment of high level fistula:
1.open the track from within the ischiorectal fossa

2.colostomy may be necessary for multiple fistulas or very high internal opening

General treatment:
1.Treatment of associated diseases like diabetes, ulcerative colitis, regional ilitis, carcinoma

2.Antibiotics - a full course of at least 2 weeks of antibiotics is needed

3.toilet and dressing of the wounds, with application of antibiotic creams

4.tub baths of the anal region several times a day in plain, warm water for about 10 minutes

What is the prognosis of Anal Fistula?
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Good with surgery.

Rarely there may undesirable complication like rectal incontinence.

A Simple Guide to Sciatica

A Simple Guide to Sciatica
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What is Sciatica?
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Sciatica is the symptom of shooting pain down the leg occurring in the sciatic nerve due to inflammation or pressure on the nerve.

What are the causes of Sciatica?
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Sciatica occur as a result of pressure on the sciatic nerve as a result of:

1.slipped disc- a prolapsed intervertebral disc which slipped out of the ligaments holding it may press against the sciatic nerve especially in the lumbar vertebrae

2.disc degeneration - flattening of the disc due to degeneration allows the discs above and below it to compress the sciatic nerve

3.Spinal stenosis- narrowing of the spinal canal can cause compression on the sciatic and other nerves

4.sacroiliatis - inflammation of the sacroliac joint cause swelling of the bones involved in the joint and may compress the sciatic nerve

5.lumbar facet syndrome-the facet bone like any bone in the body can become inflammed, swells and press against the sciatic nerve.

6.Iliolumbar syndrome- the iliolumbar ligament extends from the spine to the iliac crest when inflammed or swollen due to injury can compress the sciatic nerve

7.piriformis syndrome-the piriformis muscle lies on top of the sciatic nerve at the buttock and if inflammed, swells and press on the sciatic nerve.

8.spinal tumour- any tumour in the spine which is near the sciatic nerve may compress it.

What are the symptoms and signs of Sciatica?
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Symptoms:

1.pain may be a continous dull ache in the leg or a shooting pain down the leg

2.pain is present in the buttocks, posterior thigh, and back of outer side of the leg to ankle

3.Pain is usually but not always relieved by rest(lying flat)

4.Pain is aggravated by
a.spinal movements like flexion
b.exercises
c.straining
d.coughing
e.sneezing

5.pain is worse when sitting

6.weakness, numbness, difficulty in moving the leg

Signs:

1.Patient stands with spine rigid.
Sometimes there may sciatic scoliosis to protect the nerve roots on 1 side.

2.Straight leg raising test(SLR) which is normally up to 90 degrees is restricted

3. superficial paresthesia and sensory loss with or without tendon reflexes loss at knee or ankle and muscle weakness depending on severity and site of nerve root compression

What are the investigations required in Sciatica?
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1.Xrays of spine and pelvis for osteoarthritis, disc lesions, ankylosing spondylosis, or metastatic tumours

2.MRI of lumbar spine

3.Electromyogram and nerve conduction studies may give an an indication of the severity of damage to the nerve and the subsequent prognosis

What is the treatment of Sciatica?
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Conservative treatment:
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1.Bed rest with a hard board below the mattress- straighten the back

2.Pain killers such as NSAID(non-steroidal anti-inflammatory drugs) for pain

3.Muscle relaxant to relax muscles

4.Physiotherapy such as traction, massage or expert manipulation of the vertebrae, shortwave diathermy

5.Wearing a corset to straigthen the back and help the traction of the spinal bones

6.After the initial phase of pain is over , gradual mobilisation and exercises to strenghten the spinal extensor muscles

Surgery:
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If conservative methods fail or the pain is too severe, surgical decompression is then considered:

1.microdiscectomy - insertion of a titanium disc to replace the damaged intervertebral disc

2.laminectomy - traditional surgical removal of the damaged intervertebral disc

Finally treatment of the underlying cause is important

What is the prognosis of Sciatica?
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Prognosis depends on the underlying cause.

Mild inflammation of the muscles, ligaments may recover with conservative methods

More severe inflammation of the nerve due to disc or spinal may become worse with time.

How do you prevent Sciatica?
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Avoidance of postural strain on the back- no high heels, avoid bending the back, keep the back straight

Sleep on a hard mattress

Wear a corset

Exercises to strenghten the back muscles.