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Transperineal and Transvaginal Sonography of Perianal Inflammatory Disease

Lori K. Stewart1, Joan McGee and Stephanie R. Wilson

1 All authors: Department of Medical Imaging, Toronto General Hospital-University Health Network, 200 Elizabeth St., Toronto, Ontario, Canada M5G 2C4.



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  		Fig. 1A. —Selected schematic diagrams based on classification system by Parks et al. [3] illustrating most commonly encountered fistulas in our study population. (Reprinted with permission from [1]) Illustration of intersphincteric fistula shows infection spreading from intersphincteric anal glands caudally to skin at anal margin.

 


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  		Fig. 1B. —Selected schematic diagrams based on classification system by Parks et al. [3] illustrating most commonly encountered fistulas in our study population. (Reprinted with permission from [1]) Illustration of uncomplicated transphincteric fistula shows that in this type of fistula, infection arising in intersphincteric anal glands spreads laterally through both internal and external anal sphincters into ischioanal fossa.

 


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  		Fig. 1C. —Selected schematic diagrams based on classification system by Parks et al. [3] illustrating most commonly encountered fistulas in our study population. (Reprinted with permission from [1]) Illustration of complicated extrasphincteric fistula shows that in this type of fistula, infection of intersphincteric anal glands crosses both sphincters and spreads caudally to perineum and cranially to point above levator ani muscle at which it opens secondarily into rectum.

 


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  		Fig. 2A. —35-year-old woman with normal anal canal who was referred for investigation of proctalgia. Transvaginal axial sonogram shows mid anal canal at level at which intersphincteric glands are most densely populated. Note internal anal sphincter (white arrow) and external anal sphincter (black arrow).

 


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  		Fig. 2B. —35-year-old woman with normal anal canal who was referred for investigation of proctalgia. Transvaginal sagittal sonogram shows entire length of anal canal.

 


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  		Fig. 3A. —42-year-old man with remote total colectomy and ileoanal pouch for ulcerative colitis. Normal transperineal transverse sonogram of mid anal canal was obtained with conventional transvaginal probe.

 


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  		Fig. 3B. —42-year-old man with remote total colectomy and ileoanal pouch for ulcerative colitis. Sagittal transperineal sonogram shows normal anal canal.

 


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  		Fig. 4A. —35-year-old woman with history of perianal abscess. At physical examination, external opening was noted on perineum. Findings on contrast sinogram were negative. Transverse sonogram of mid anal canal shows transphincteric fistula (arrow) extending posteriorly into abscess collection (arrowhead).

 


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  		Fig. 4B. —35-year-old woman with history of perianal abscess. At physical examination, external opening was noted on perineum. Findings on contrast sinogram were negative. Oblique transperineal sonogram shows portion of fluid-filled tract (arrows) extending from abscess (A) to external opening (double arrow) on perineum.

 


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  		Fig. 5. —45-year-old woman with no known history of bowel disease but with recurrent perianal abscess. Transverse transvaginal sonogram of mid anal canal shows multiple blind-ending intersphincteric sinus tracts (arrow) and large horseshoe-shaped ischioanal abscess (arrowhead).

 


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  		Fig. 6A. —43-year-old multiparous woman with previous subtotal colectomy for ulcerative colitis who was referred to rule out rectovaginal fistula. Oblique transverse sonogram obtained transvaginally shows defect in external and internal and sphincter (between arrowheads) and gas-filled fistulous tract (arrows) extending from lumen of anal canal to posterior vaginal wall.

 


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  		Fig. 6B. —43-year-old multiparous woman with previous subtotal colectomy for ulcerative colitis who was referred to rule out rectovaginal fistula. Transvaginal sagittal sonogram also shows gas-filled fistula (arrows) extending from lumen of anal canal to posterior vaginal wall.

 


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  		Fig. 7A. —18-year-old man with Crohn's disease and two previous surgeries for perianal suppuration who was referred to rule out occult infection. No external openings were seen on perineum. Sonography revealed complex disease. Transverse suprapublic sonogram at supralevator levels shows intramural fluid collection (arrow) with particulate debris in rectal wall.

 


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  		Fig. 7B. —18-year-old man with Crohn's disease and two previous surgeries for perianal suppuration who was referred to rule out occult infection. No external openings were seen on perineum. Sonography revealed complex disease. Sagittal transperineal sonogram shows posterior fluid collection (arrow) extending caudally in intersphincteric location to most inferior aspect of anal canal.

 


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  		Fig. 7C. —18-year-old man with Crohn's disease and two previous surgeries for perianal suppuration who was referred to rule out occult infection. No external openings were seen on perineum. Sonography revealed complex disease. Transverse transperineal sonogram of mid anal canal shows internal opening (arrowhead) posteriorly at 6 o'clock position. Bulk of caudal aspect of perianal and perirectal abscess (arrow) extends cranially in intersphincteric plane.

 


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  		Fig. 7D. —18-year-old man with Crohn's disease and two previous surgeries for perianal suppuration who was referred to rule out occult infection. No external openings were seen on perineum. Sonography revealed complex disease. Transverse transperineal sonogram more caudally in anal canal than C shows additional transphincteric sinus tract with internal opening at 11 o'clock position (arrow). This tract crosses both internal and external anal sphincter and extends into right ischioanal fossa at which it ends blindly.

 

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