"Diagnosis" is by examination, either in an outpatient setting or under anaesthesia (referred to as — Examination Under Anaesthesia). The fistula may be explored by using a fistula probe (a narrow instrument). In this way, it may be possible to find both openings. The examination can be an anoscopy. Diagnosis may be aided by performing a fistulogram, proctoscopy and/or sigmoidoscopy.

Possible findings:

- The opening of the fistula onto the skin may be observed

- The area may be painful on examination

- There may be redness

- An area of induration may be felt — thickening due to chronic infection

- A discharge may be seen

CLASSIFICATIONS of ANAL FISTULA

- Park's Classification: This was done in 1976 by Parks et al from UK. This was done in the era when MRI or Endoanal Ultrasound was not there. It classified the fistula in four grades

- St James University Hospital Classification: This was done by Morris et al in the year 2000. This classification was improvement over Parks classification as it was based on MRI studies. It classified the fistula in five grades.

- Garg Classification: This was done by Pankaj Garg in 2017. This classification is improvement over both Parks and St James University Hospital Classification. This was based on MRI studies and operative findings in 440 patients. It classified the fistula in five grades. The grades of this classification correlate quite well with the severity of the disease. Grade I & II are simpler fistulas and can be managed by Fistulotomy whereas grade III-V are complex fistulas in which fistulotomy should be not be done. They should be managed by Fistula experts. Unlike Park's and St James University Hospital Classification, this correlation is quite accurate with Garg's classification. Therefore this new classification is useful to both surgeons and radiologists

Vesicovaginal fistulae are typically repaired either transvaginally or laparoscopically, although patients who have had multiple transvaginal procedures sometimes attempt a final repair through a large abdominal incision, or laparotomy.

The laparoscopic (minimally invasive) approach to VVF repair has become more prevalent due to its greater visualization, higher success rate, and lower rate of complications.

Other conditions in which infected perianal "holes" or openings may appear include Pilonidal cysts/sinuses.

Birth injuries that result in the formation of fistulas and urinary and fecal incontinence have been found to be strongly associated with economic and cultural factors. Teenagers and women who sustain injuries that develop into ureterovaginal fistulas during childbirth suffer significant social stigma. Ureterovaginal fistulas related to prolonged, obstructed labor are rare in developed nations but are more common in countries where access to emergent obstetrical care is limited.

Many women delay treatment for decades. Surgeons often will correct the fistula through major gynecological surgery. Newer treatments can include the placement of a stent and is usually successful. In 0.5-2.5% of major pelvic surgeries a ureterovaginal fistula will form, usually weeks later. If the fistula cannot be repaired, the clinician may create a permanent diversion of urine or urostomy. Risks associated with the repair of the fistula are also associated with most other surgical procedures and include the risk of adhesions, disorders of wound healing, infection, ileus, and immobilization. There is a recurrence rate of 5%–15% in the surgical operation done to correct the fistula.

After diagnosing rectovaginal fistula, it is best to wait for around 3 months to allow the inflammation to subside. For low fistulae, a vaginal approach is best, while an abdominal repair would be necessary for a high fistula at the posterior fornix.

A circular incision is made around the fistula and vagina is separated from the underlying rectum with a sharp circumferential dissection. The entire fistulous tract, along with a small rim of rectal mucosa is incised. The rectal wall is then closed extramucosally.

Most rectovaginal fistuals will need surgery to fix. Medications such as antibiotics and Infliximab might be prescribed to help close the rectovaginal fistula or prepare for surgery.

It is often caused by childbirth (in which case it is known as an obstetric fistula), when a prolonged labor presses the unborn child tightly against the pelvis, cutting off blood flow to the vesicovaginal wall. The affected tissue may necrotize (die), leaving a hole.

Vaginal fistulas can also result from particularly violent cases of rape, especially those involving multiple rapists and/or foreign objects. Some health centers in countries such as the Democratic Republic of Congo have begun to specialize in the surgical repair of vaginal fistulas.

It can also be associated with hysterectomy, cancer operations, radiation therapy and cone biopsy.

Colostomy is recommended by most surgeons, and has a good prognosis, with 90% of patients regaining normal bowel control. Since the rectal opening and anal orifice in a vestibular fistula tend to be short and narrow, a colostomy is usually performed to allow decompression of the bowel unless the orifice is wide enough to allow normal defecation. Colostomy is often followed by posterior sagittal anorectoplasty (PSARP), a surgical procedure to repair the anal orifice, at a later date. Some surgeons prefer to perform an immediate PSARP without a colostomy first, while others perform neither a colostomy nor a PSARP and instead opt for a simple dilatation of the orifice to allow stool to pass and the bowel to decompress. It has been suggested that only experienced surgeons should perform repair without an initial colostomy.

Rectovaginal fistulas are often the result of trauma during childbirth (in which case it is known as obstetric fistula) where improper medical interventions are used, such as episiotomy with forceps/vacuum extraction or in situations where there is inadequate health care, such as in some developing countries. Rectovaginal fistula is said to be known as the leading cause in maternal death in developing countries. Risk factors include prolonged labour, difficult instrumental delivery and paramedian episiotomy. Rates in Eritrea are estimated as high as 350 per 100,000 vaginal births. Fistulas can also develop as a result of physical trauma to either the vagina or anus, including from rape. Women with rectovaginal fistulae are often stigmatized in developing countries, and become outcasts.

Rectovaginal fistula can also be a symptom of various diseases, including infection by lymphogranuloma venereum, or the unintended result of surgery, such as episiotomy or sexual reassignment surgery. They may present as a complication of vaginal surgery, including vaginal hysterectomy. They are a recognized presentation of rectal carcinoma or rarely diverticular disease of the bowel or Crohn's disease. They are seen rarely after radiotherapy treatment for cervical cancer.

Various modalities of diagnosis are available:

- Cystoscopy

- Colonoscopy

- Poppy seed test

- Transabdominal ultrasonography

- Abdominopelvic CT

- MRI

- Barium enema

- Bourne test

- Cystogram

A definite algorithm of tests is followed for making the diagnosis.

In developing countries, women who are affected by obstetric fistulae do not necessarily have full agency over their bodies or their households. Rather, their husbands and other family members have control in determining the healthcare that the women receive. For example, a woman's family may refuse medical examinations for the patient by male doctors, but female doctors may be unavailable, thus barring women from prenatal care. Furthermore, many societies believe that women are supposed to suffer in childbirth, thus are less inclined to support maternal health efforts.

The diagnosis of a rectovestibular fistula can be made in female newborns if the vulva is stained with meconium (the earliest form of stool in an infant). The opening of the anus may be difficult to see due to its small size and position, but it may be visible as a thickening of the median perineal raphe with an obvious anal dimple. Patients with rectovestibular fistulae are commonly misdiagnosed with rectovaginal fistulae.

Prevention is the key to ending fistulae. UNFPA states that, “Ensuring skilled birth attendance at all births and providing emergency obstetric care for all women who develop complications during delivery would make fistula as rare in developing countries as it is in the industrialized world.” In addition, access to health services and education – including family planning, gender equality, higher living standards, child marriage, and human rights must be addressed to reduce the marginalization of women and girls. Reducing marginalization in these areas could reduce maternal disability and death by at least 20%.

Prevention comes in the form of access to obstetrical care, support from trained health care professionals throughout pregnancy, providing access to family planning, promoting the practice of spacing between births, supporting women in education, and postponing early marriage. Fistula prevention also involves many strategies to educate local communities about the cultural, social, and physiological factors of that condition and contribute to the risk for fistulae. One of these strategies involves organizing community-level awareness campaigns to educate women about prevention methods such as proper hygiene and care during pregnancy and labor. Prevention of prolonged obstructed labor and fistulae should preferably begin as early as possible in each woman's life. For example, improved nutrition and outreach programs to raise awareness about the nutritional needs of children to prevent malnutrition, as well as improve the physical maturity of young mothers, are important fistula prevention strategies. It is also important to ensure access to timely and safe delivery during childbirth: measures include availability and provision of emergency obstetric care, as well as quick and safe cesarean sections for women in obstructed labor. Some organizations train local nurses and midwives to perform emergency cesarean sections to avoid vaginal delivery for young mothers who have underdeveloped pelvises. Midwives located in the local communities where obstetric fistulae are prevalent can contribute to promoting health practices that help prevent future development of obstetric fistulae. NGOs also work with local governments, like the government of Niger, to offer free cesarean sections, further preventing the onset of obstetric fistulae.

Promoting education for girls is also a key factor to preventing fistulae in the long term. Former fistula patients often act as "community fistula advocates" or "ambassadors of hope," a UNFPA-sponsored initiative, to educate the community. These survivors help current patients, educate pregnant mothers, and dispel cultural myths that obstetric fistulae are caused by adultery or evil spirits. Successful ambassador programs are in place in Kenya, Bangladesh, Nigeria, Ghana, Côte d'Ivoire, and Liberia.

Several organizations have developed effective fistula prevention strategies. One, the Tanzanian Midwives Association, works to prevent fistulae by improving clinical healthcare for women, encouraging the delay of early marriages and childbearing years, and helping the local communities to advocate for women's rights.

Doctors uses a variety of tools and techniques to evaluate the type of anorectal disorder, including digital and anoscopic investigations, palpations, and palpitations. The initial examination can be painful because a gastroenterologist will need to spread the buttocks and probe the painful area, which may require a local anesthetic.

Low-output fistula: < 200 mL/day

Moderate-output fistula: 200-500 mL/day

High-output fistula: > 500 mL/day

Treatment for fistula varies depending on the cause and extent of the fistula, but often involves surgical intervention combined with antibiotic therapy.

Typically the first step in treating a fistula is an examination by a doctor to determine the extent and "path" that the fistula takes through the tissue.

In some cases the fistula is temporarily covered, for example a fistula caused by cleft palate is often treated with a palatal obturator to delay the need for surgery to a more appropriate age.

Surgery is often required to assure adequate drainage of the fistula (so that pus may escape without forming an abscess). Various surgical procedures are commonly used, most commonly fistulotomy, placement of a seton (a cord that is passed through the path of the fistula to keep it open for draining), or an endorectal flap procedure (where healthy tissue is pulled over the internal side of the fistula to keep feces or other material from reinfecting the channel). Treatment involves filling the fistula with fibrin glue; also plugging it with plugs made of porcine small intestine submucosa have also been explored in recent years, with variable success. Surgery for anorectal fistulae is not without side effects, including recurrence, reinfection, and incontinence. High rate of recurrence and more chances of complications like incontinence are always there in fistula surgeries (Anal Fistula).

It is important to note that surgical treatment of a fistula without diagnosis or management of the underlying condition, if any, is not recommended. For example, surgical treatment of fistulae in Crohn's disease can be effective, but if the Crohn's disease itself is not treated, the rate of recurrence of fistula is very high (well above 50%).

Low-output fistula: < 500 mL/day

High-output fistula: > 500 mL/day

Imaging by ultrasonography, MRCP, or CT scan usually make the diagnosis. MRCP can be used to define the lesion anatomically prior to surgery.

Occasionally Mirizzi's syndrome is diagnosed or confirmed on ERCP when requested to alleviate obstructive jaundice or cholangitis by means of an endoscopically placed stent, or when USS has been wrongly reported as choledocolithiasis.

Treatments range from recommendations for over-the-counter products to more invasive surgical procedures.

Among the most common outpatient advice given to patients with less severe disorders include a high-fiber diet, application of ointment, and increased water intake. More serious procedures include the removal of affected tissue, injection of botulinum toxin, or surgically opening the fistula tract in the sphincter muscle.

Various types of fistulas include:

Although most fistulas are in forms of a tube, some can also have multiple branches.

It is surgically corrected, with resection of any fistula and anastomosis of any discontinuous segments.

Diagnosis is made by patient history of passing air or a sputtering urine stream. CT scans may show air in the urinary bladder or bladder walls.

Clinical features can be found in the subhyoid portion of the tract and 75% present as midline swellings. The remainder can be found as far lateral as the lateral tip of the hyoid bone.

Typically, the cyst will move upwards on protrusion of the tongue, given its attachment to the embryonic duct, as well as on swallowing, due to attachment of the tract to the foramen caecum.

The risk of the development of a lymphocele is positively correlated to the extent of the removal of lymphatic tissue during surgery (lymphadenectomy). Surgery destroys and disrupts the normal channels of lymph flow. If the injury is minor, collateral channels will transport lymph fluid, but with extensive damage, fluid may accumulate in an anatomic space resulting in a lymphocele. Typical operations leading to lymphocysts are renal transplantation and radical pelvic surgery with lymph node removal because of prostatic or gynecologic cancer. Other factors that may predispose of lymphocele development are preoperative radiation therapy, heparin prophylaxis (used to prevent deep vein thrombosis), and tumor characteristics. After radical surgery for cervical and ovarian cancer studies with follow-up CT found lymphoceles in 20% and 32%, respectively. Typically they develop within 4 months after surgery.

Imperforate anus usually requires immediate surgery to open a passage for feces unless a fistula can be relied on until corrective surgery takes place. Depending on the severity of the imperforate, it is treated either with a perineal anoplasty or with a colostomy.

While many surgical techniques to definitively repair anorectal malformations have been described. The posterior sagittal approach (PSARP) has become the most popular. It involves dissection of the perineum without entry into the abdomen and 90% of defects in boys can be repaired this way.