What is the optimal treatment plan for a middle-aged patient with internal cloth soiling, a normal sigmoidoscopy, a PR (per rectal) mucosal bulge on the left side, and a pelvic MRI showing a mass on the left side at the levator ani, with no external opening?

From the Guidelines

The optimal treatment plan for this patient with internal cloth soiling, normal sigmoidoscopy, left-sided PR mucosal bulge, and pelvic MRI showing a mass at the levator ani without external opening is surgical excision of what appears to be an intersphincteric anal gland abscess or fistula, with the most appropriate approach being examination under anesthesia followed by surgical drainage and fistulotomy or placement of a seton if a complex fistula is identified, as recommended by the WSES-AAST guidelines 1. The patient's clinical presentation is consistent with an anorectal abscess that has developed from infected anal glands, which commonly occurs at the intersphincteric space.

• Key considerations in the management of this patient include:
  • Preoperative broad-spectrum antibiotics, such as metronidazole 500mg three times daily plus ciprofloxacin 500mg twice daily for 5-7 days, to control infection 1
  • Post-surgery, the patient will need sitz baths 2-3 times daily, regular dressing changes, and follow-up appointments to monitor healing
  • Pain management with acetaminophen and/or NSAIDs is typically sufficient
• The WSES-AAST guidelines suggest that the management of patients with known Crohn’s disease goes beyond the aims of these guidelines, but it is mandatory to exclude the presence of undiagnosed underlying Crohn’s disease in every patient presenting with an anorectal abscess, especially if recurrent 1
• A focused and detailed medical history is of utmost importance, and complete physical examination should include a careful inspection of the perineum checking for surgical scars, anorectal deformities, other signs of perianal Crohn’s disease, the presence of secondary cellulitis, or the presence of external opening of an anal fistula 1
• The use of laboratory and radiological studies is not usually needed for the diagnosis of an anorectal abscess but can be useful in specific situations, such as in patients with signs of systemic infection or sepsis 1
• The clinical presentation suggests an anorectal abscess that has developed from infected anal glands, which commonly occurs at the intersphincteric space, and without proper surgical intervention, these conditions rarely resolve spontaneously and can progress to more complex fistulas or recurrent abscesses, potentially compromising sphincter function and continence over time 1.

From the Research

Optimal Treatment Plan

The optimal treatment plan for a middle-aged patient with internal cloth soiling, a normal sigmoidoscopy, a PR mucosal bulge on the left side, and a pelvic MRI showing a mass on the left side at the levator ani, with no external opening, can be determined based on the provided evidence.

• The patient's condition suggests a complex anorectal fistula, which can be treated with various surgical techniques, including:
  • Ligation of the Intersphincteric Fistula Tract (LIFT)
  • Fistulotomy
  • Seton placement
  • Sealing by glue
• Studies have shown that LIFT is a effective and preferred sphincter-saving technique for fistula-in-ano, with shorter healing time and lower incidence of postoperative anal incontinence, as compared to open fistulotomy 2, 3, 4, 5.
• However, a recent study compared high ligation of the inter-sphincteric fistula tract via lateral approach (modified LIFT) and Fistulotomy and primary sphincteroplasty (FIPS) in the management of high trans-sphincteric fistula, and found that FIPS is an effective and preferred technique for the trans-sphincteric fistula repair with high statistically significant lower incidence of recurrence in one-year follow-up as compared to modified LIFT technique 6.
• Based on the evidence, the optimal treatment plan for this patient would be:
  • LIFT (Ligation of the Intersphincteric Fistula Tract) or
  • Fistulotomy and primary sphincteroplasty (FIPS)

Comparison of Treatment Options

• LIFT:
  • Advantages: shorter healing time, lower incidence of postoperative anal incontinence
  • Disadvantages: may not be suitable for all types of fistulas
• Fistulotomy and primary sphincteroplasty (FIPS):
  • Advantages: high statistically significant lower incidence of recurrence in one-year follow-up
  • Disadvantages: may have a higher incidence of incontinence to gases only post-operative
• Seton placement:
  • Advantages: can be used as a temporary measure to drain the fistula and reduce symptoms
  • Disadvantages: may not be a definitive treatment for the fistula
• Sealing by glue:
  • Advantages: minimally invasive procedure
  • Disadvantages: may not be effective for all types of fistulas, and the evidence for its use is limited 2, 3, 4, 5, 6.