|Year : 2015 | Volume
| Issue : 4 | Page : 173-175
Fistula in ano presenting as postcoital scrotal discharge
Abhishek Bose1, Sandeep Sharma2, Jaspal Singh3, Harmandeep S Chahal2
1 Department of Urology and Kidney Transplant, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Urology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
3 Department of Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
|Date of Submission||26-Nov-2014|
|Date of Decision||28-Jan-2015|
|Date of Acceptance||10-Mar-2015|
|Date of Web Publication||28-Aug-2015|
S/O, Late Dr. Arvind Bose, Madarpur Mogulpura, Darbhanga - 846 004, Bihar
Source of Support: None, Conflict of Interest: None
A 32-year-old male presented to us with the history of purulent discharge from scrotum since 5 months ago, with increased amount of discharge during sexual intercourse. Magnetic resonance imaging showed a fistula tract ending at the root of the penis. However, intraoperatively it was found to be communicating with the anal canal. Fistula in ano rarely presents with an external opening in the scrotum. We could not find any published literature in this regard. Complex fistula in ano therefore should be considered in cases of scrotal discharging sinus.
Keywords: Intercourse, scrotal sinus, fistula in ano, scrotal fistula, complex fistula, perianal fistula, anal fistula
|How to cite this article:|
Bose A, Sharma S, Singh J, Chahal HS. Fistula in ano presenting as postcoital scrotal discharge. J Med Sci 2015;35:173-5
| Introduction|| |
Sinuses and fistulae in the scrotum is a known entity. Urethroperineal or scrotal fistula is a known complication of a periurethral abscess.  Fistula in ano presenting with the scrotal discharge has not been reported in the literature. To the best of our knowledge, this is the first report of fistula in ano presenting with discharges during sexual activity.
| Case Report|| |
A 32-year-old male presented to us with a discharging sinus from scrotum since 5 months ago. The discharge started after a previously noticed cord-like thickening in the scrotum, and it ruptured during sexual intercourse. After this event, the wound failed to heal with the occasional observation of watery discharge. The discharge would have increased during sexual activities. There was no history of lower urinary tract symptoms (LUTS), dysuria, fever, hematuria, loose stool, constipation, bleeding per rectum, or any discharge per urethra. This patient denied any exposure to outside wedlock and he had no systemic disorders such as diabetes mellitus or tuberculosis. On examination, his body mass index was 31.8 kg/m 2 . Grossly, the sinus appeared over the median raphe with its tract more on the right side of the bulb of the penis. Digital rectal examination was not performed at initial presentation. The cord-like thickening was found to end at the root of penis [Figure 1]. There was no palpable lymphadenopathy, and his testes and epididymis all appeared normal. The complete blood count and renal function tests were within normal limits. The test for the human immunodeficiency virus was negative. Urine analysis showed four to five pus cells per high-power field, but the urine culture was negative. Ultrasonography of the urinary tract showed no abnormality, and the residual urine was acceptable. Magnetic resonance imaging (MRI)-sinogram further demonstrated a sinus ending at the root of penis [Figure 2]. There was not enough discharge at the time of presentation for bacteriological culture. Urethrocystoscopy was performed for him, but the inner opening of the discharging sinus was not found. Only by injection of methylene blue dye into the sinus tract, the drainage was found to appear from the rectum. Proctoscopy showed a fistulous opening in the upper part of the anal canal with a bubbling mixture of methylene blue and hydrogen peroxide. Focused per rectal examination under anesthesia confirmed a button like internal opening in the upper border of anal canal. A malleable probe was passed into the tract through the external and internal openings. It appeared that the fistulous tact had an angulation at the root of the penis with communication with the anal canal and the scrotum on either side. The scrotal opening of the fistula was laid open (fistulotomy) over a malleable probe and curettage done for the remaining tract. The resected tissue was sent for histopathological examination, and it showed chronic inflammatory changes without any evidence of granulomas. The long fistula was divided in the ischiorectal fossa through a fresh incision. A draining/fibrosing seton was inserted in the upper part of the fistula and brought through the new opening created over the ischiorectal fossa. A cutting seton was inserted into the anal canal and brought out through the previously created wound in the ischiorectal fossa. He was discharged with a seton, which was tightened up thereafter in every 15 days. The patient was kept on sitz baths, analgesics, and stool-bulking agents in follow-up care, and remained symptom-free during the follow-up period.
|Figure 1: A malleable probe passed through the scrotal sinus and brought out through a fresh opening created over the ischiorectal fossa. Gloved fi nger inside the anal canal helped to guide the probe|
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|Figure 2. Magnetic resonance imaging sinogram showing sinus tract ending at the root of penis|
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| Discussion|| |
Our case had an unusual presentation of having increased discharge after sexual activity. The absence of LUTS suggested that urethra was not involved. However, worsening of symptoms during sexual intercourse suggested it's possible anatomical contact of genital organs, e.g., the seminal vesicles. MRI-sinogram could not reveal any such communication. Finally, it provisionally diagnosed to be a blind-ending tract (sinus) and its excision was planned. Only by intraoperative injection of methylene blue dye along with hydrogen peroxide revealed its communication with anal canal. A diagnosis of fistula in ano with external opening over scrotum was made. Because of high and complex nature of the fistulous tract, a part of the fistula was laid open and the remaining was kept on a seton, allowing the fibrosis to heal the tract.
The increase in the amount of discharge during sexual intercourse was possible as a result of direct squeezing by perineal muscle. The contraction of pelvic or bulbocavernosus muscle might increase the pressure inside the fistula and further caused the content of the fistula to overflow. Fistula in ano generally presents with seropurulent discharge from the perianal area, and the external opening is generally visible with a palpable tract. Low fistulas with internal opening below the anorectal bundle can be managed by fistulotomy, a procedure to open along the length of the fistulous tract. Chronic fistula often needs fistulectomy which consists of excision of entire fibrous tissue including the tract. Setons are used in cases of complicated high fistulae wherein a fistulotomy can result in anal incontinence. This was the reason of using cutting setons in our case. In our case, the fistulous tract followed the classical Goodsall's rule and had a straight tract anteriorly up to the scrotum.
Magnetic resonance imaging is the study of choice for evaluating complex or recurrent fistulas. However, in our case, the MRI failed to pick the communication between the fistula and the anal canal. The emergence of the fistulous opening on injection of methylene blue mixed with hydrogen peroxide might be because the bubbles of oxygen create a pressure which in turn allow even stenotic fistulous tract to open up.
Fistula involving the perineum and scrotum has been known in cases of gonorrhea and nongonococcal urethritis.  And the associated urethral stricture allows urine to pass form the narrow fistulous tract from the urethra to the perineum or scrotum. Consequently, urination usually occurs through the perianal fistulas, which results in the so-called "watering can perineum".  Fistulas involving the scrotum can also be found in tuberculosis, schistosomiasis, perianal actinomycosis,  perianal Crohn's disease, anorectal malformations,  and after strangulated inguinal hernia. 
| Conclusion|| |
Fistula in ano should be considered in cases presenting with scrotal discharge or sinus. A combination of imaging and clinical examination is required to accurately map the fistula.
| References|| |
Sanders CJ, Mulder MM. Periurethral gland abscess: Aetiology and treatment. Sex Transm Infect 1998;74:276-8.
Pandhi D, Reddy BS. Watering can perineum: A forgotten complication of gonorrhoea. J Eur Acad Dermatol Venereol 2002;16:486-7.
Sharfi AR, Elarabi YE. The 'watering-can' perineum: Presentation and management. Br J Urol 1997;80:933-6.
Coremans G, Margaritis V, Van Poppel HP, Christiaens MR, Gruwez J, Geboes K, et al.
Actinomycosis, a rare and unsuspected cause of anal fistulous abscess: Report of three cases and review of the literature. Dis Colon Rectum 2005;48:575-81.
Duman K, Ozdemir Y, Yigitler C, Gulec B. Rectocutaneous fistula with imperforate anus in an adult. Singapore Med J 2013;54:e85-7.
Malik P, Rathi M, Kumar K, Sharma R, Meena P, Arya A, et al.
Scrotal enterocutaneous fistula: A rare initial presentation of inguinal hernia. J Surg Case Rep 2014;2014:rju056.
[Figure 1], [Figure 2]