What is the Goodsall rule? (2023)

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What is the Goodsall's rule?

Goodsall's rule (GR) states that if the external opening of an anal fistula is anterior to a transverse line across the anus will open radially into the anterior wall of the anal canal provided it is less than 3 cm from the anal verge, else it will open in the midline posteriorly.

What is Goodsall's rule for fistula?

Goodsall's rule states that a fistula with the external opening anterior to an imaginary transverse line across the anus has its internal opening at the same radial position and for an external opening posterior to this line, the internal opening is in the midline posteriorly with a horse-shoe track.

What is the percentage of Goodsall's rule?

Results: Predictive accuracy of Goodsall's rule found to be 84.6% in case of fistula with an anterior external opening. While in case of fistula with posterior external opening this found to be 69.1%. Overall predictive accuracy of Goodsall's rule is 77%.

What is the average size of a fistula?

Most surgeons arbitrarily classify a fistula as low when it can be repaired from a perineal approach and as high if it can be approached only transabdominally. The size of recto-vaginal fistulae ranges from less than 0.5 cm (small) to more than 2.5 cm (large).

What is Goodsall's rule uptodate?

One of the most commonly cited principles to assist in the surgical management of an anal fistula is Goodsall's rule, which states that all fistula tracks with external openings within 3 cm of the anal verge and posterior to a line drawn through the ischial spines travel in a curvilinear fashion to the posterior ...

What is 6 o'clock position in fistula?

The level at which the external sphincter complex is traversed is most often at the mid-anal canal level and the internal opening is usually at around 6 o'clock, at the level of dentate line. This is, however, not invariable.

What is the mnemonic for ano fistula?

A multitude of causes cause fistulas, but the well-known mnemonic "FRIEND" here aids memory. "F" for foreign body, "R" radiation, "I" infection or Inflammatory Bowel Disease, "E" epithelialization, "N" neoplasm, and "D" for distal obstruction (as is the case in the cryptoglandular theory).

What is the minimum vein diameter for a fistula?

Vein diameter is an independent predictor for fistula maturation. A diameter of 2.5 mm has been established as the minimum vein size predictive of fistula success.

Which method is best for fistula?

Conclusion: MRI is the optimal technique for discriminating complex from simple perianal fistula, although AES is superior to clinical examination, and may be used if MRI availability is restricted.

What is Seton's procedure?

Seton techniques

A seton is a piece of surgical thread that's left in the fistula for several weeks to keep it open. This allows it to drain and helps it heal, while avoiding the need to cut the sphincter muscles. Loose setons allow fistulas to drain, but do not cure them.

What is considered a large fistula?

In using size as a criterion, fistulas less than 2.5 cm in diameter are considered small; those greater than 2.5 cm are described as large. The location of a rectovaginal fistula can be described in relation to the rectum, vagina, and rectovaginal septum.

Do fistulas get bigger over time?

Over time, your fistula should get larger, extending past the lines drawn on your arm when your access was created.

How many years does a fistula last?

An AV fistula can last for years—even decades. Fistulas are the access least prone to infections and blood clots. Most people can have an AV fistula. If you have a blood vessel disease, a pacemaker, or other health problems, a fistula may not work for you.

What is the probability of fistula closure?

If the patient attains good nutritional status, remains free of sepsis, and has fistula output that progressively decreases, conservative treatment may be continued. The spontaneous closure rate of intestinal fistulas is reported as 30-80%.

What is the first rule of 6 in fistula?

1. “Rule of six” in fistula assessment — at six weeks post-creation the diameter of the body of the fistula should be at least 6mm and the depth no more than 0.6cm. The blood-flow rate should be 600mL/min or more by this time. The length of the fistula should be 6cm to allow for a successful two-needle dialysis.

What is considered high fistula output?

Physiologic classification of fistulas is based on output (in ml per day). High output fistulas (greater than 500 ml per day) are more likely to originate from the small bowel. Low output fistulas (less than 200 ml per day) are more likely to be colonic in origin.

What is Grade 4 fistula?

A trans-sphincteric fistula with an abscess or an additional tract in the ischiorectal fossa is classified as a grade IV. In contrast, a supra-levator or trans-levator fistula is denoted as grade V. This classification, based on MRI findings of the pelvis, provides an objective preoperative assessment for the surgeon.

What is the difference between a fistula and a fissure in the ano?

You would be mistaken to think that fistula and fissure are the same. Fissure is a medical term referring to the tearing of the skin, whereas fistula is abnormal tube-like connections or passages between organs. Generally, fissures can get cured in a few days or few weeks, often without even needing any treatment.

What is the best diagnostic test for fistula-in-ano?

Endoscopic ultrasound, which uses high-frequency sound waves, can identify the fistula, the sphincter muscles and surrounding tissues. Fistulography is an X-ray of the fistula that uses an injected contrast to identify the anal fistula tunnel. Examination under anesthesia.

How do you treat a fistula-in-ano without surgery?


Your surgeon may recommend inserting a seton as an initial step to fistula treatment without surgery. This procedure is used if your fistula is passing through a significant portion of the anal sphincter muscle. Seton is a piece of surgical thread left in the fistula to keep it open for several weeks.

What is a good flow rate for a fistula?

In the end, you can't have it both ways unless UNLESS you dialyse longer. I prefer, advise, and prescribe longer, slower, dialysis with fistula-gentle blood flow rates of 325 ml/min or less in our facility-based patients and, in our home nocturnals, a mean of 225 ml/min.

How deep should a fistula be?

A useful rule of thumb to define clinical maturation proposed by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative clinical practice guidelines for vascular access is the “rule of sixes,” which says that a mature fistula should achieve a blood flow of at least 600 ml/min, a diameter of at ...

What angle is a fistula needle?

The needle should be held at a 20- to 35-degree angle for AV fistulas, and at approximately a 45-degree angle for grafts. 6 Once the needle has been advanced through the skin, subcutaneous tissue, and graft or fistula wall, the blood flashback should be visible.

What are the three common fistulas?

The three most common AVFs are the radiocephalic fistula, the brachiocephalic fistula, and the brachial artery-to-transposed basilic vein fistula.

What are the three types of fistula?

Types Of Fistulas
  • Anorectal fistulas occur between the anal canal and the skin around the anal opening.
  • Rectovaginal or Anovaginal fistulas occur when a hole develops between the rectum or anus and the vagina.
  • Colovaginal fistulas occur between the colon and the vagina.

Does a seton ever stop draining?

Drainage can continue for a number of weeks following placement of the seton. Please do not overdo bathing and wiping of your bottom and area around your fistula. This will make you sore. Try to keep the area clean and dry.

Is a cutting seton painful?

However, the traditional cutting seton technique often needs 2 or even several times to tighten the thread. Because of the abundant nerves in the anal region, tightening the seton brings great pain to patients, which affects the clinical application of the therapy.

What is the difference between cutting and non cutting setons?

A noncutting Seton maintains drainage of the fistula, thereby reducing the risk of perianal abscess formation. It also promotes fibrosis and helps in fistula closure. Cutting Setons are used to cut through the fistula. The Seton is passed through the fistula and tightened (instead of loose as in non cutting Seton).

What is the most common serious fistula?

The most common form of fistula – anal fistula—can occur naturally with time.

Is fistula a disability?

People with conditions that increase the risk of anal fistula (for example, Crohn's disease) may also be considered to have a disability if the condition has similar effects on daily living.

What is the easiest fistula to treat?

Characteristics of a simple fistula include a single tract, subcutaneous tract, and those that involve less than 30% of the external sphincter. A simple fistula is the easiest to treat and has the lowest recurrence and complication rates.

What should you not do with a fistula?

Keep it clear - do not wear a watch or tight clothing on your fistula arm. Try not to sleep on that side of your body and avoid having your blood pressure or blood tests taken from that arm.

What is the most known consequence of fistulas?

Complications related to enterocutaneous fistulas are common and include sepsis, malnutrition, and fluid or electrolyte abnormalities. Intestinal failure is one of the most feared complications of enterocutaneous fistula management and results in significant patient morbidity and mortality.

Can you live with a fistula without surgery?

Fistula tracts must be treated because they will not heal on their own. There is a risk of developing cancer in the fistula tract if left untreated for a long period of time. Most fistulas are simple to treat. Either the tract or fistula can be opened or the tract and the pocket inside are completely removed.

What is the average age for a fistula?

Anal fistulas occur most often in adults around the age of 40 but may occur in younger people, especially if there is a history of Crohn's disease. Anal fistulas occur more often in males than in females.

When should a fistula be removed?

While some fistulas can be treated with antibiotics and other medication, fistula removal surgery may be necessary if the infection doesn't respond to medication or if the fistula is severe enough to require emergency surgery.

Is life normal after fistula surgery?

There is a higher risk of infection and incontinence with this type of surgery. A person may need several weeks to feel better and may need to stay home from work for a few days. After a person fully recovers, in most cases, the fistula heals, and a person will not have lingering issues such as incontinence.

What is the theory of fistula?

The cryptoglandular theory of perianal fistulas suggests their development from the proctodeal glands, which originate from the intersphincteric plane and perforate the internal sphincter with their ducts. A connection forms between an opening at the level of the dentate line and another in the perianal area.

What is the clock position of a perianal fistula?

Goodsall's rule states that the internal opening of the fistula is dependent on where the fistula is located relative to the 'anal clock' (i.e. with the patient in the lithotomy position, anterior is 12 o'clock and posterior is 6 o'clock) and the transverse anal line (a line drawn from 9 o'clock to 3 o'clock):

What is the clock position of fistula in ano?

Internal opening of fistulas is described in accordance with the anal clock system: 12 o'clock denotes anterior, while 6 o'clock points posterior. Internal opening of fistulas are usually located at the level of the dentate line (5) except for the extrasphincteric fistulas.

What is a fistula example?

Examples of naturally occurring fistulas are those that form between the end of the bowel and skin near the anus (anal fistula) or between the intestine and the vagina (enterovaginal fistula). Fistulas may also form between the rectum and the vagina and this is called a rectovaginal fistula.

What are the rules of 6 fistula?

1. “Rule of six” in fistula assessment — at six weeks post-creation the diameter of the body of the fistula should be at least 6mm and the depth no more than 0.6cm. The blood-flow rate should be 600mL/min or more by this time. The length of the fistula should be 6cm to allow for a successful two-needle dialysis.

What is the difference between a low and high perianal fistula?

Low perianal fistulas are defined as fistulas of which the fistula tract is located in the lower third of the external anal sphincter. High fistulas are fistulas in which the fistula tract runs through the upper two-thirds of the external sphincter muscle. Low perianal fistulas can be treated safely by fistulotomy.

What is the most common site of perianal fistula?

These fistulas often arise in the more proximal rectum rather than the anus and are often sequelae of a procedure. Their external opening is in the perianal area and the tract courses superiorly to enter the anal canal above the dentate line.

What is the most successful fistula surgery?

A fistulotomy is the most effective treatment for many anal fistulas. But it's usually only suitable for fistulas that do not pass through much of the sphincter muscles. This is because the risk of incontinence is lowest in these cases.

What is 11 o'clock fistula?

The condylomata of the tract is visible. The commonest sights of appearance of condylomata acuminata are the genital and anal regions. Herein we present two cases of condylomata within fistulae tracts, resulting in recurrence in one case and a malignant-like tumour in the second.

What is the recurrence rate of fistula in ano after surgery?

The chances of recurrence in different types of anal fistulae range between 7% and 50% [16-18].

Which is the best fistula in ano treatment?

Fistulectomy is usually recommended for low anal fistulas, as the success rate is high with this procedure, and with minimal incontinence. The success rates can be as high as 93 to 100 % in experienced hands [28, 29]. The incontinence is usually minor and can range from 11.5 to 20 %.


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