Horseshoe Fistula: Symptoms, Diagnosis, and Modern Surgical Treatment

A horseshoe fistula is a complex type of anal fistula that may significantly affect daily life, hygiene, and quality of life. Patients commonly experience symptoms such as discharge, recurrent infection, discomfort while sitting, and persistent staining of underwear. Although the condition can be chronic and recurrent, modern surgical techniques allow for safe and effective treatment. In this article, we will discuss what a horseshoe fistula is, how it develops, how it is diagnosed, which treatment options are available, and what to expect after surgery.

 

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What Is a Horseshoe Fistula?

 

 

The term “horseshoe fistula” refers to a fistulous tract that originates posteriorly from the anal canal and extends laterally to both sides, forming a horseshoe-shaped configuration. Compared to standard anal fistulas, horseshoe fistulas are more difficult to manage due to their anatomical complexity and tendency to recur.

 

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Causes and Underlying Mechanisms

 

 

Most horseshoe fistulas develop as a result of cryptoglandular infection. When an anal gland becomes blocked, infection may form an abscess. If the abscess does not drain adequately, a fistulous tract may develop over time. In some patients, recurrent abscess formation may be the first sign of a developing fistula. Rarely, inflammatory bowel diseases such as Crohn’s disease may contribute to fistulization.

 

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Who Is Affected?

 

 

Horseshoe fistulas can occur in both men and women, although they appear more frequently in younger and middle-aged men. Occupations involving prolonged sitting, chronic constipation, or hygiene-related issues may contribute to symptom severity, although they are not direct causes.

 

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Symptoms and Patient Complaints

 

 

Patients commonly report:

 

• Discharge: persistent moisture, staining, or odor

• Pain: particularly pronounced during abscess episodes

• Recurrent infection: repeated abscess formation

• Sitting discomfort: affecting daily activities

• Irritation and itching: due to chronic moisture

• Hygiene difficulties: requiring frequent cleaning or dressing changes

 

 

These symptoms may interfere with social life and work performance, and can be particularly distressing due to issues of odor and hygiene.

 

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How Is a Horseshoe Fistula Diagnosed?

 

 

Accurate diagnosis is essential for successful treatment. The primary goals of diagnosis are to determine the course of the fistula tract, detect any secondary extensions, and assess the relationship between the tract and the sphincter complex.

 

Diagnostic evaluation may include:

 

1. Clinical Examination: provides initial assessment.

2. Endoanal Ultrasound: reveals sphincter involvement and internal tract anatomy.

3. MRI: the most valuable tool for mapping horseshoe fistulas; detects extensions, secondary pockets, and abscess collections.

4. Observation of Discharge: provides insight into chronicity and tract function.

 

 

MRI findings are particularly useful for surgical planning and reducing recurrence rates.

 

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Treatment Principles

 

 

Treatment aims to:

 

• Control infection

• Achieve adequate drainage

• Preserve sphincter function

• Minimize recurrence

• Improve quality of life

 

 

For these reasons, treatment is often performed in staged or combined fashion.

 

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Surgical Treatment Options

 

 

Treatment selection depends on anatomical characteristics, previous interventions, degree of sphincter involvement, and presence of abscess.

 

 

1. Modified Hanley Procedure

 

 

The Modified Hanley procedure is a well-established technique in horseshoe fistulas. A posterior midline approach provides effective drainage and reduces recurrence while preserving sphincter function.

 

 

2. Seton Treatment

 

 

Setons offer controlled drainage and remain one of the mainstays of treatment:

 

• Loose Seton: used primarily to drain infection and control discharge.

• Tight Seton: selected cases may benefit from gradual division of the tract while preserving continence.

 

 

Staging treatment provides flexibility for complex fistulas.

 

 

3. Laser Treatment (FiLaC)

 

 

FiLaC is a minimally invasive approach that ablates the fistulous tract using radial laser energy. Pain may be milder and healing faster than conventional procedures. Not all horseshoe fistulas are suitable for FiLaC; patient selection is important. It may be used alone or in combination with a seton.

 

 

4. THD/LIFT or Endoscopic Approaches

 

 

Hybrid treatment strategies are sometimes preferred for complex cases to optimize sphincter preservation and decrease recurrence rates.

 

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Recurrence and Outcomes

 

 

Horseshoe fistulas have higher recurrence rates than standard fistulas due to complex anatomy and drainage challenges. Surgical experience and individualized treatment planning significantly improve outcomes and reduce recurrence risk.

 

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Postoperative Care and Recovery

 

 

After surgery, postoperative care focuses on:

 

• Pain control

• Hygiene

• Dressing changes

• Diet and constipation avoidance

• Gradual return to daily activities

 

 

Long-term continence and improvement in quality of life are key goals.

 

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When to Seek Medical Attention

 

 

Persistent discharge, recurrent abscess episodes, sitting discomfort, or staining of underwear are important warning signs. Patients experiencing such symptoms should be evaluated by a proctologist.

 

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Approach at the Clinic of Op. Dr. Hakan Bayri

 

 

Treatment for horseshoe fistulas is tailored to the patient. A combination of minimally invasive and conventional surgical techniques may be used to preserve sphincter function and reduce recurrence.

 

Address: Kızılırmak Mahallesi, Dumlupınar Bulvarı No:9A, YDA Center, 19th Floor, No:747, Ankara

Phone: +90 537 022 15 42 – +90 547 530 40 40

 

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For Consultation and Appointments

 

 

Patients who seek evaluation or wish to discuss treatment options may schedule a consultation.