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DISCHARGE INSTRUCTIONS AFTER FISTULOTOMY

PAUL E. SAVOCA, MD, FACS, FASCRS

An anal fistula is an abnormal channel or tunnel-like chronic infection that starts inside the anus and ends outside on the skin around the anus. Its development is usually the result of a previous anal infection or abscess. About 50% of people with an anal abscess end up with a fistula. Most fistulas are short and superficial and are best treated by simply opening the entire tunnel and leaving it open to heal in gradually. Occasionally a patient can have a complex fistula with multiple tracts or the tunnel may traverse a considerable amount of the sphincter muscle. For this reason the surgical treatment has to be individualized for each particular patient depending on the location and anatomy of the fistula. Frequently, the surgeon cannot guarantee exactly what will need to be done until the examination that is done under anesthesia at the time of the surgery. It is important to realize that the operative procedure can change depending on what is found at the time of the surgery. At times a fistula will require more than one surgery to cure.

During a simple fistulotomy the tract is opened and left to heal. Sutures are sometimes used to narrow the wound but not close it completely. If it is decided that the fistula is too deep or in a bad position to open it completely, a small drain- called a seton – may be inserted. Your surgeon will explain how this will be managed in the future.

Discharge Instructions:
Following your fistulotomy, you may experience some mild to moderate pain or discomfort in your rectal area. You may also experience constipation, difficulty urinating, and possibly some rectal bleeding. The following are some general guidelines for proper care after your procedure.

Home Care:
A small amount of bleeding is common following rectal surgery. A sanitary napkin or gauze may be worn over the anal opening to keep the underclothing clean. When there is no longer any bleeding or discharge, there is no need to keep the pad in place. If there is prolonged or profuse bleeding with passage of clots, call the office at once.

Difficulty urinating after fistulotomy is unusual, but can occur due to spasm of the urinary sphincter resulting from pain due to the surgery. Getting the pain under control and relaxing the sphincter usually allows for the urine to pass. Take the pain medication you were prescribed and do warm sitz baths – either in a bath tub or sitz basin. While soaking, attempt to relax the bladder and urinate into the water. If you are unable to urinate in the first eight hours after your surgery, notify the doctor’s office. After hours, go to the nearest emergency room or urgent care center. A bladder catheter will be placed and remain in place for 2 days, you may call the office to have the catheter removed. Once you have started to urinate, drink plenty of water and fruit juices (such as prune juice) after your surgery.

You will be given a prescription for pain medication. Follow the directions given by your doctor for taking this medication. After a day or two, if the pain is subsiding try to use just plain Tylenol to ease residual discomfort. To avoid upset stomach, take your pain medication as prescribed with food in your stomach.

Take these drugs exactly as directed. Never take more than the recommended dose, and do not take the drugs more often than directed. If the drugs do not seem to be working, call the office for advice. Do not share these or any other prescription drugs with others because the drug may have a completely different effect on the person for whom it was not prescribed.

Some people experience drowsiness, dizziness, lightheadedness, or a false sense of well being after taking opioid analgesics. Anyone who takes these drugs should not drive, use machines, or do anything else that might be dangerous until they know how the drug affects them. Nausea and vomiting are common side effects, especially when first beginning to take the medicine. If these symptoms do not go away after the first few doses, check with the physician who prescribed the medicine. Side effects may include: dizziness, lightheadedness, nausea, sedation, vomiting, if these side effects occur, it may help if you lie down after taking the medication.

  • Avoid strenuous activity for 1 week after your procedure.
  • Take sitz baths (sit for 15-20 minutes in warm water) three times a day and after each bowel movement for the first few days.
  • If you were given a topical ointment, place this over the anal skin and a little into the anal canal 2-3 times a day.
  • Don’t worry if you have some bleeding, discharge, or itching during your recovery. This is normal.
  • Avoid constipation.
    • Take Benefiber or other psyllium product (Metamucil, Citrucel, Konsyl, etc) one teaspoon twice a day. Take a stool softener such as Colace or Surfak twice a day as well.
    • If you have not had a bowel movement by the morning of the fourth day following surgery, take 2 fleet enemas, 1 hour apart (lubricate the tip of the enema well with Vaseline and insert gently). If no result, drink one bottle of citrate of magnesium, which can be purchased at any pharmacy. Following the first bowel movement, you should have a bowel movement at least every other day. If 2 days pass without a bowel movement, take an ounce of milk of magnesia. Repeat in 6 hours if no result.
    • The use of dry toilet tissue should be avoided. After bowel movements use a wet Kleenex, cotton or Tuck’s pads to clean yourself, or if possible, take a warm bath.
    • If you were given a prescription for an ointment, apply this two or three times a day at the edge of the anal opening.
  • Eat a regular diet including plenty of fresh fruit and vegetables. Drink 6-8 glasses of water a day.
  • Call the office if your temperature is greater than 101 degrees.

Follow-Up
Make a follow-up appointment as directed by our staff. The first follow up is usually 3 weeks following surgery, but if a seton was placed the surgeon may want to see you sooner.