Evaluation of the risk factors needed to be considered in patients having unusual or persistent disease prior management of fistula-in-ano: Experience in a peripheral medical college hospital of Bangladesh

Background: Fistula-in-ano is a chronic abnormal connection between the anal canal and perianal skin, often resulting from unresolved anorectal abscesses. It poses significant clinical challenges due to recurrence, morbidity, and potential quality-of-life impacts, particularly in males aged 30-50. In resource-limited settings like Bangladesh, atypical or persistent cases are challenging to diagnose due to limited access to advanced imaging. Risk factors such as Crohn’s disease, tuberculosis, diabetes, repeated surgeries, or malignancy complicate management. Accurate diagnosis, risk factor identification, and individualized treatment are crucial to avoid complications. Comprehensive evaluation and clinical vigilance are essential for effective outcomes, especially where diagnostic support is minimal. Aim of the study: The present study aims to analyze the relevant risk factors in patients presenting with unusual or persistent fistula-in-ano at a peripheral medical college hospital in Bangladesh. Methods: This cross-sectional observational study was conducted over 12 months (from January 2023 to December 2023) in a Peripheral Medical College Hospital in Dinajpur, Bangladesh, enrolling 50 purposively selected patients aged ≥18 years with clinically or radiologically diagnosed recurrent, complex, or persistent fistula-in-ano. Data were collected using structured questionnaires and clinical proformas, documenting sociodemographic details, clinical features, risk factors, investigations, and treatment. Diagnostic tools included fistulograms, MRI, USG, and relevant lab tests. Fistulas were classified using Parks' system, and management included fistulotomy, seton placement, LIFT, or conservative approaches. Outcomes, including wound healing and recurrence, were evaluated over at least six months. Data were analyzed using SPSS version 26 and Microsoft Excel. Results: Among the 50 patients studied, 84% were male, and most were aged 31-40. Discharge (92%), pain (76%), and swelling (60%) were the most common symptoms. Poor perianal hygiene (56%), smoking (50%), and chronic constipation (40%) were key risk factors. Inter-sphincteric (40%) and trans-sphincteric (30%) fistulas predominated. Diagnostic tools like fistulograms (80%) and MRI/endoanal ultrasound (40%) aided in complexity assessment. Fistulotomy was the most common treatment (44%). The mean wound healing time was 4.2±1.5 weeks. Recurrence occurred in 20%, infections in 12%, and one patient developed incontinence. 74% achieved a complete cure, while 26% had persistent or recurrent disease. Conclusion: This study emphasizes the need to address key risk factors and utilize early, individualized management for unusual or persistent fistula-in-ano. Despite effective treatment, recurrence and complications remain concerns, highlighting the importance of improved diagnostics, patient education, and standardized protocols, especially in resource-limited peripheral healthcare settings.