PA and FIA are common findings in infants and children. Infants tend to have a relatively higher incidence of PA/FIA than older children, and boys tend to have a relatively higher incidence of PA/FIA than girls [8, 9]. Consistent with the literature, male predominance (73.7% of infants and 47.2% of children) was noted in our study group.
In a study by Ezer et al., PA and FIA were most frequently observed at 9 o’clock and 3 o’clock [5]. Afsarlar et al. divided the perianal region into four quadrants of a clock. They found that the most common site of PAs and FIAs in both infants and children was the fourth quadrant. In addition, they found that PAs in the first and third quadrants were more likely to develop into FIAs compared to the second and fourth quadrants; the difference in this comparison was statistically significant [10]. In our study, it was observed that PAs developed into FIAs more frequently in the second quadrant.
The approach in our clinic for every patient who presents with a PA or FIA is to recommend warm sitz baths and local wound care and to start antibiotic treatment. The fluctuating abscess is treated with ID without anesthesia as an outpatient. Clinical relief is observed in patients with incisional drainage. Conservative treatment without antibiotics alone is not used in any cases.
PA and FIA in infancy are characterized by a self-limiting process. Left on its own, the abscess will usually drain out of the skin on its own, causing symptoms to subside. Recent studies show that PA and FIA in infants are usually self-limiting, and the conservative approach is the first-line treatment in this age group, and surgery should be preferred for complex fistulas and failed conservative treatment [11]. In our study, 35.9% of patients with PA under 1 year of age were left to spontaneous drainage, while 32.2% of patients over 1 year of age were left to spontaneous drainage. There was no statistical difference between the age groups in terms of treatment approach (p = 0.79).
Incision and drainage are the most traditional and commonly performed operational procedures. Incision and drainage of the abscess are recommended for patients with fluctuation for more than 4 days from onset without signs of abscess perforation or diffusion. The use of antibiotics after incision and drainage can effectively shorten the clinical course and reduce the spread of abscess or fistula formation [10, 12]. In our study, ID therapy was applied to 64.1% of patients with PA. Treatment of PA with ID remains the treatment of choice in many centers, as it provides faster pain relief and wound healing compared to spontaneous drainage (SD) [13, 14]. Among the patients who were treated surgically, 29% were reported to have FIA in the further course [12]. In our study, the rate of FIA development was found to be 1.8% in the patients treated with ID, while the rate of development of FIA in those treated with SD was 27.9%. Statistically, the rate of fistula development was found to be higher in patients with SD (p = 0.001).
The most conservative management includes topical treatment and waiting for spontaneous emptying of the abscess and healing. This approach has an increasing effect on local inflammation, especially in infants. The frequency of anal fistula development has been reported to reach 77% with this type of conservative management [15].
In their study, Charalampopoulos et al. observed that no fistulas developed during follow-up in any of the babies who underwent drainage [13]. It has been reported in the literature that the incidence of PA converting to FIA varies but can be up to 85% in children [15, 16]. In our study, conversion to FIA was observed at a rate of 10.7%. Also, the development of FIA was significantly higher after SD. In our cases, we found that early incisional drainage of PA decreased the development of FIA.
After a fistula develops, if conservative treatment fails, surgical treatment is recommended [17]. In our study, 10 (11.5%) of the patients who were followed up with FIA in our clinic recovered without surgery after antibiotics and conservative treatment. Studies have found that after the removal of a FIA (fistulotomy or fistulectomy), the frequency of recurrence in children is lower (12–15%) [5, 17]. In our study, in accordance with the literature, no recurrence of FIA was observed in any of our treated patients surgically.
The principal limitation of this study is that the data were obtained retrospectively from patient records. Another limitation is that patients could not be compared in terms of conservative treatment, since all patients received antibiotic treatment. Randomized prospective studies are needed to compare appropriate treatment approaches.
