Conservative Treatment

Spontaneous healing can occur in about half of all patients who still have an unhealed wound 12 months after rectal excision, if the diagnosis is ulcerative colitis; almost all persistently discharging wounds will have healed in 18-24 months. Even in Crohn's disease some perineal sinuses can heal spontaneously up to 12 months after proctocolectomy [16]. The patient should be advised and instructed to take an active part in the daily care of the wound. Simple sitz baths are rarely sufficient, and a regular use of a small shower-like "Water Pik" (Water Pik Technologies Inc., CA, USA) will favour a correct wound cleansing. The dressing should not be too tight to deter mechanical delay of the healing process. Topical antibiotic agents are sometimes useful to alleviate symptoms such as pain, pruritus and local inflammation while systemic antibiotics cannot usually reach therapeutic tissue concentrations [18] and are generally less helpful.

Adequate debridement of the perineal wound with surgical removal of all devitalised and infected tissue is of great importance. Unfortunately, the presence of multiple tracks or abscess on the buttocks or surrounding perineal skin often interferes with the above-mentioned local procedures. It is usually advisable to examine all fistulae under anaesthesia in order to define its exact position, dilate any strictures present and collect some samples for histology and cultures [16]. A daily irrigation of the cavity with antiseptic solution is effective in reducing purulent discharge [20]. In selected cases, oral metronidazole and low doses of steroids may be confidently used to reduce inflammation.

Special and complex dressings have been empirically used over the years to help closure. Among the many different types of advanced dressings, subat-mospheric pressure dressings (SPD) are safe and easy to manage. The wound is filled with a sterile sponge, a silastic drain tube is placed on top and the system is sealed with airtight plastic drape. The tube is connected to a vacuum device or a vacuum bottle to maintain the wound bed at subatmospheric pressure. A vacuum allows higher blood flow in the wound bed favouring granulation tissue formation and absorbs exudates thus reducing bacterial contamination. This method has been adopted in many cases with good results [8, 21, 22].

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