The seton method used in the treatment of anal fistula is an important treatment technique that ensures infection drainage by keeping the fistula tract open. Anal fistula is a condition that must definitely be treated. Because if left untreated, inflammations spreading in the region over time can lead to the formation of other fistulas and more serious health problems in the advanced process.
Seton application is a technique developed especially to heal the fistula line in a controlled manner and protect the sphincter muscles without affecting your defecation functions. While the seton method is generally preferred in high and complex fistulas, the biggest advantage of this treatment is the cleaning of fistulas embedded within the sphincter muscle. In addition, since approximately 90% of the formed fistulas have a simple structure, early treatment is of great importance. In this article, you will find answers to the questions of what seton treatment is, how it is applied, and in which cases it is used in a clear and understandable language.
What is an Anal Fistula and Why Should It Be Treated?
An anal fistula is an abnormal tunnel- or channel-like connection formed between the inside of the anus and the skin surrounding it. It comes from the Latin word fistula, meaning "tube," and is most commonly seen in the perianal region. This condition does not heal on its own and definitely requires medical intervention.
Fistula formation process
An anal fistula usually develops as a result of an infection or abscess developing around the anus. It is estimated that a fistula develops in one out of every two to four people with an anal abscess. The process progresses as follows: One of the glands in the anal region becomes inflamed, and this inflammation accumulates in a closed space to form an abscess. An untreated abscess finds its way out with increasing pressure inside, thus creating a channel extending from the inner surface of the anus to the outer surface.
Other factors causing fistula formation include chronic diarrhea, hard bowel movements, inflamed anal fissures, and intestinal parasites. In addition, chronic bowel diseases such as Crohn's disease also increase the risk of developing a fistula.
Symptoms and impact on quality of life
The most prominent symptoms of an anal fistula are:
Continuous or intermittent discharge around the anus (usually foul-smelling)
Throbbing pain that increases during sitting, moving, and defecation
Swelling, redness, and tenderness around the anus
Itching and skin irritation
Pus or blood coming during defecation
Difficulty controlling bowel movements in some cases
These symptoms significantly restrict daily life. Due to constant pain, discomfort, and discharge, patients have difficulty sitting, and their work and social lives are adversely affected. Especially the discharge and bad odor can reduce a person's self-confidence and lead to psychological problems.
What happens if left untreated?
Serious consequences arise when the treatment of an anal fistula is delayed or ignored. First of all, an anal fistula never heals on its own. Untreated fistulas:
Become chronic and turn into a continuous source of infection
Create recurrent abscesses, and each abscess bursting lays the groundwork for the formation of new fistula tracts
Can spread to wider areas over time and become increasingly difficult to treat
Can lead to fecal incontinence problems by damaging the anal sphincter muscles
Can cause permanent tissue damage in the long run
In rare cases, the risk of cancer in the region may increase
For these reasons, an anal fistula should be treated immediately when detected. Different methods are used in treatment depending on the type and location of the fistula. One of these is the seton method. Seton treatment is especially preferred to protect the sphincter muscles and heal the fistula in a controlled manner.
What is the Seton Method and How Does It Work?
The seton method used in the treatment of anal fistula appears as an important technique in the treatment of complex fistulas. But what exactly is this treatment method and how does it work? In this section, we will examine seton application in detail.
What is seton application?
Seton application is essentially a special thread placed inside the anal fistula. In this method, a thin thread or a medical material is passed through the fistula tract and wraps around the fistula. This thread can be of a stretchable rubber or silicone structure. The procedure is usually performed under general anesthesia or spinal anesthesia, and the patient can mostly return home on the same day.
During the surgical procedure, the fistula tract is first found with the help of a special probe, and then a seton is placed in this tract. Thus, the inflammation inside the fistula channel is allowed to flow out, preventing abscess formation. This method, which is especially preferred in complex (transsphincteric) anal fistulas crossing the sphincter muscles, helps protect the muscles.
What does the seton thread do?
The seton thread, as a thin thread placed in the fistula in the shape of a ring or hoop, has several important functions. Thanks to this thread, the fistula channel is kept open and drainage of the inflammation is ensured. Thus, the infection is expelled and prevented from accumulating in a closed space and forming new abscesses.
In addition, the seton is placed at the inner and outer opening of the fistula remaining between the muscles, ensuring the controlled cutting of the muscles in the region. This situation helps protect the sphincter muscles. By protecting the muscles, it reduces the risk of complications that could affect the function of holding stool and gas.
One of the biggest advantages of seton application is that it does not damage the anal muscles that allow us to hold stool and gas. This is a situation that directly affects the quality of life.
What is seton treatment?
Seton treatment is a technique applied both to bring the infection under control and to close the fistula channel used in the treatment of anal fistula. In this treatment, there are different approaches depending on the way the seton is applied:
Loose Seton: Only drainage and infection control are targeted.
Cutting Seton: Ensures the controlled closure of the fistula by being tightened over time.
Hybrid Seton: Provides both drainage and helps the safe closure of the fistula tract.
Seton treatment is mostly a staged process. Usually, the seton is left in place for a few months and healing is monitored. Additional interventions may be required in some cases. For example, narrowing the seton, replacing it, or intervening with laser or another surgical method after the seton.
As a result, the seton method is an effective technique used especially in complex anal fistula cases to control infection and provide treatment by protecting the sphincter muscles without lowering the quality of life.
Seton Types and In Which Cases They Are Used
Setons used in the treatment of anal fistula are applied in different types depending on the type of fistula and the patient's condition. In this section, we will examine the varieties of setons and in which cases they are preferred.
Loose seton
Loose seton application helps drain inflammation by keeping the fistula tract open. As the name suggests, this type of seton is not tied tightly and aims only to keep the fistula path open rather than cutting it. First of all, it prevents the recurrence of abscess formation by allowing the infection to flow out.
Loose seton application is generally painless and provides an advantage in terms of patient comfort. Since this type of seton does not cut tissues, it does not harm the anal muscles and does not lead to problems such as gas-stool incontinence. In addition, it can be left in the body for an average of 3-4 months and mostly falls out on its own.
Cutting seton
A cutting seton is an application that ensures the controlled closure of the fistula by being tightened over time. In this method, the fistula path is gradually cut using setons made of rubber material. However, the sphincter muscle can also be cut during this procedure.
Since it usually falls out on its own within 2-3 weeks, the treatment period is shorter. However, the cutting seton is not preferred much today due to the feeling of discomfort and pain it causes the patient and the damage it creates in the anal muscles as a result.
Hybrid and medicated setons
Hybrid seton is a combination of cutting and loose seton methods used in the treatment of anal fistula. This modern approach accelerates healing by providing both drainage and a gradual cutting effect. In particular, it aims to clean the infected channel without damaging the sphincter muscle and provide controlled healing from the inside out.
Hybrid seton treatment can be performed with a single-session application and there is usually no pain after the surgery. The patient can return to daily activities the very next day. The average healing time with this method is 6-8 weeks, and according to the 2024 ESCP guideline, the recurrence rate is 30% lower than classical setons.
In medicated setons, materials impregnated with antibacterial or other drugs are used to try to reduce the risk of infection.
Selection of seton according to fistula type
The selection of a seton according to the type of fistula is of great importance. In particular, one of the most important steps in seton treatment is the selection of the material that will cause the least discomfort to the patient. Setons made of thin rubber materials are more easily tolerated by patients and make a significant contribution to comfort.
Hybrid seton is ideal for complex (transsphincteric or suprasphincteric) fistulas because the fistula line passes through the sphincter muscles and classical surgical methods carry the risk of incontinence. In recurrent fistulas, a high success rate can be achieved with hybrid seton in patients who have previously undergone laser, LIFT, or fistula plug methods and experienced recurrence.
In patients who develop a permanent fistula after abscess drainage, the hybrid seton ensures complete cleansing of the inflammation and controlled closure of the tissues. In addition, it is preferred in patients where sphincter function needs to be preserved (especially in women with sphincter weakness due to birth trauma or individuals with decreased muscle tone in older age).
As a result, the choice of seton type is determined by the proctologist according to the location, depth of the fistula, and the specific condition of the patient. Correct seton selection directly affects treatment success.
Seton Application Process and Healing Stages
If you are going to receive seton treatment, you will want to know how the whole process works from surgery to recovery. In this section, we explain the stages of fistula seton application and the healing process.
How is fistula seton surgery performed?
Seton application is usually performed under local or general anesthesia. Spinal anesthesia may also be preferred. Before the surgery, your doctor evaluates your condition by performing necessary examinations.
First, the surgeon identifies the fistula tract with the help of a special probe and cleans the inflamed tissue inside. Then, a seton is placed between the inner and outer openings of the fistula. A stretchable rubber or silicone thread is used in this procedure.
Surgery usually takes 15-20 minutes, but this time may be prolonged in complex cases. After the procedure is completed, most patients can return home on the same day, hospitalization is not required.
How long does the recovery period take?
The recovery period in seton treatment varies depending on the size of the fistula and the general health status of the patient. Treatments performed with a cutting seton usually last 6-8 weeks, while loose seton applications can take longer.
Although the average healing process is 3-4 months, this period can extend up to 6-12 months in complex fistulas and horseshoe fistulas. Regular check-ups and dressings are important during this period.
However, you can return to daily life shortly after the seton is placed. Especially patients who undergo hybrid seton application can mostly start their normal activities the next day.
When does the seton thread fall out?
The time for the seton thread to fall out varies depending on the technique applied and the tension of the thread. When a tight (cutting) seton is used, the thread usually falls out on its own within 2-3 weeks.
The loose seton stays in place for a longer time and can be present in the body for an average of 3-4 months. If loose applications are made for drainage purposes, it does not fall out until a second procedure is possible.
If a hybrid seton application has been made, it can fall out on its own within 2-3 weeks depending on the form of application. If the seton falls out early, you should definitely consult your doctor.
Post-surgery care recommendations
It is normal to have mild bleeding and discharge in the area after surgery. This condition usually lasts for a few weeks and decreases over time. As long as the discharge continues, you should gently clean the area with warm water.
Things to consider after surgery:
Avoid heavy exercises, prolonged running, and cycling
Be careful not to stay constipated, consume fibrous foods and drink plenty of water if necessary
Keep the area clean and dry, but do not wash excessively
Do not neglect your doctor check-ups
It is possible to have a comfortable recovery process after seton application. You can successfully complete this process by following doctor recommendations and with regular check-ups.
Advantages of the Seton Method and Comparison with Other Methods
There are a few different methods in the treatment of anal fistula, but seton application offers significant advantages in many cases. Why does this treatment method, which is preferred in complex fistulas, stand out more in some cases compared to others? In this section, we will examine the advantages of the seton technique and its comparison with other treatments.
Preserving the sphincter muscle
The most important advantage of the seton method is that it protects the anal muscles (sphincters) that allow us to hold stool and gas. Especially in applications made as "loose," the anal muscles are completely protected, while in hybrid applications, damage remains at a minimal level. Seton application is applied to the muscle group called the sphincter, providing controlled healing in the fistula line. In complex cases where the fistula passes through all of the internal and external muscles that provide continence, using a seton is the safest option to protect the muscles.
In traditional surgical methods such as fistulotomy, the sphincter muscle may need to be cut. This situation can create a risk of gas or stool leakage (incontinence) in patients. However, while the muscles are slowly cut with seton application, the body's healing mechanism is also activated at the same time, thus preventing the complete separation of the muscle.
Reducing the risk of abscess
The other important advantage of seton treatment is that it breaks the abscess-fistula-abscess vicious cycle. A properly placed seton keeps the fistula tract open, allowing the inflammation inside to flow out. Thus, the recurrence of the abscess is prevented and the existing cavity is enabled to shrink.
In untreated fistulas, inflammation can accumulate inside due to the closed outer hole and form an abscess again. These new abscesses can burst in different places and form new fistula tracts. The seton prevents this situation by providing continuous drainage between the inner and outer openings of the fistula. In addition, bleeding after seton application is extremely normal and passes on its own within a few weeks.
Differences with fistulectomy and laser treatment
Seton treatment is generally a long-term treatment and can take an average of 6-12 months. In contrast, fistulectomy (complete removal of the fistula tract) can provide faster results. However, fistulectomy carries the risk of damaging the sphincter muscles.
Laser treatment appears as a technological alternative. Although the laser procedure, which can be performed with less harm to the body, seems advantageous, the success rate is not as high as classical surgeries. While laser treatment is reported to be successful at a rate of 50-70% in fistula patients, the seton method success rate can go up to 90%.
When we compare in terms of pain, when pain levels are evaluated on a scale of 0-10 one week after surgery:
Laser treatment: 1 (0-5)
Seton placement: 4.2 (2-6)
Fistulotomy: 5 (3-8)
Fistulectomy: 6.8 (5-9)
As a result, the seton method is preferred especially in complex fistulas involving the sphincter muscles. Sometimes it can also be used for bridging purposes - that is, while laser treatment is planned, it can be applied temporarily beforehand to bring the fistula under control. Thus, the next treatment can be more successful.
Frequently Asked Questions
There are many questions that patients wonder about after seton application. Knowing the answers to these questions before starting treatment both reduces your anxieties and accelerates your recovery process.
Can you go to the toilet while having a seton?
Yes, you can go to the toilet normally while the seton is in place. The seton thread stays like a small ring inside the anus and does not prevent defecation. You may feel a slight sting in the first few days, but this condition is temporary. Feeding with fibrous foods and drinking plenty of water provides soft defecation, reducing pain and accelerating healing. After using the toilet, it is sufficient to clean and dry the area only with warm water. Excessive cleaning and leaving it damp can cause skin irritation and itching.
What happens if the seton thread falls out early?
The seton is made of a durable material, but early falling out or breaking can sometimes be seen. In such a case, definitely do not intervene on your own and consult your doctor immediately. If the seton falls out before the fistula tract is completely closed, the doctor can place a new seton if necessary or suggest a different treatment method. Since the seton breaking and falling out can negatively affect the treatment process, doctor control is a must.
When to return to work after seton?
Patients with a seton can usually return to their daily activities within 1-2 days. Desk workers can start work within a few days. For people doing heavy physical work, a few weeks of rest may be recommended by the doctor. Since the healing process varies from person to person, it is the most accurate approach for your doctor to determine the time to return to work.
Will there be gas or stool leakage?
In correctly applied seton treatment, the problem of gas or stool leakage is almost never seen. The most important advantage of seton treatment is that it protects the sphincter muscles. Especially in loose and hybrid seton techniques, the anal muscles are not damaged, thus patients heal without losing toilet control. Rarely, there may be a minimal possibility of weakness in very deep fistulas; in this case, your surgeon will make the necessary evaluations.
Seton Application in Summary
As a result, the seton method in the treatment of anal fistula is an effective treatment option preferred especially in complex cases. As you have seen in this article, untreated fistulas can lead to more serious health problems over time. Therefore, it is of great importance to consult a specialist as soon as you notice the symptoms.
Seton application offers significant advantages in protecting your anal muscles compared to other methods. Especially in fistulas involving the sphincter muscle, it protects these muscles and prevents your ability to hold gas and stool from being damaged. In addition, by keeping the fistula tract open, it provides inflammation drainage and prevents recurrent abscess formation.
This method, which has different types such as loose seton, cutting seton, and hybrid seton, can be personalized according to the characteristics of your fistula. Following your doctor's instructions during the treatment process, going to regular check-ups, and keeping the area clean will accelerate your healing.
Remember that an anal fistula does not heal on its own and can become more complex if postponed. However, it is possible to get rid of this condition completely with the right treatment. Since the appropriate treatment method can vary according to the location, type of fistula, and your personal characteristics, you must make the treatment decision together with an expert proctologist.
Although seton treatment is generally a long-term process, you can return to your daily life in a short time. With this treatment method applied correctly, success rates of up to 90% can be achieved and your quality of life can be significantly improved.
The seton method in anal fistula treatment ensures infection drainage while protecting the sphincter muscles. In this article, discover what seton treatment is and in which cases it is used.
