![]() The Parks classification has become the most widely used surgical classification for distinguishing four types of fistula. if the internal opening is posterior to the transverse anal line there will be a tortuous (and often more complex) fistulous tract that enters posteriorly in the midline (6 o'clock).if the internal opening is anterior to the transverse anal line there will be a (usually simple) direct radial fistulous tract.with the patient in the lithotomy position, anterior is 12 o'clock and posterior is 6 o'clock) and the transverse anal line (a line drawn from 9 o'clock to 3 o'clock): Goodsall's rule states that the internal opening of the fistula is dependent on where the fistula is located relative to the 'anal clock' (i.e. ![]() Suprasphincteric fistulae are due to supralevator abscesses. Intersphincteric fistulae are due to perianal abscesses. Transsphincteric fistulae are secondary to ischiorectal abscesses, with a resultant extension of the tract through the external sphincter. The most commonly accepted pathophysiology is the cryptoglandular hypothesis, which suggests that obstruction of the deep submucosal glands results in infection and abscess formation in the intersphincteric space, which consequently drains inferiorly between the sphincters, opening onto the skin surface or, less commonly, erodes through both the internal and external sphincters into the ischiorectal space, then onto the skin surface 4. Symptoms are variable, including anal pain, tenesmus, pruritus, and sepsis. it is unclear if ulcerative colitis is a risk factor for perianal disease 11.diverticulitis: perhaps the most common cause in developed countries.Incidence is estimated at ~1:10,000 1, with a recognized male predilection of 2-4:1.
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