Fissure-in-Ano and Fistula-in-Ano
The relationship between the neuromuscular physiology of the anus and the presence of an anal fissure often drives operative and nonoperative management strategies in modern day medicine. One such example is the use of bran and sitz baths as first-line therapy for acute fissure-in-ano. Fistula-in-ano is a challenging anorectal disease to manage. Identifying the anatomy of the tract is particularly important for obtaining operative cure and minimizing fecal incontinence. Once the external opening, internal opening, and tract are identified, treatment is dependent on the type of fistula, best classified by Dr. Parks, another pioneer in the field of proctology. Extrasphincteric fistulae are the least common type of fistula. Extrasphincteric fistulae include a tract that passes from the perianal skin through the ischiorectal fossa and levator ani muscle and terminates in the rectal wall. Fistulectomy is mainly a historical procedure that was used for fistulae that involved a significant amount of anal sphincter muscle such as transsphincteric and suprasphincteric fistulae.