Last updated July 25, 2022

Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula

Initial Evaluation of Anorectal Abscess and Fistula

A disease-specific history and physical examination should be performed evaluating symptoms, relevant history, abscess and fistula location, and presence of secondary cellulitis. (1C)
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Routine use of diagnostic imaging is not typically necessary for patients with anorectal abscess or fistula. However, imaging may be considered in selected patients with an occult anorectal abscess, recurrent or complex anal fistula, immunosuppression, or anorectal Crohn’s disease. (1B)
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Anorectal Abscess

Patients with acute anorectal abscess should be treated promptly with incision and drainage. (1C)
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Abscess drainage with concomitant fistulotomy may be performed in selected patients with simple anal fistulas. (2B)
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Antibiotics should typically be reserved for patients with an anorectal abscess complicated by cellulitis, systemic signs of infection, or underlying immunosuppression. (2B)
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Anal Fistula

Patients with a simple fistula-in-ano and normal anal sphincter function may be treated with lay-open fistulotomy. (1B)
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Fistula-in-ano may be treated with endorectal advancement flap. (1B)
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Transsphincteric fistulas may be treated with ligation of the intersphincteric fistula tract (LIFT) procedure. (1B)
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A cutting seton may be used selectively in the management of complex cryptoglandular anal fistulas. (2C)
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The anal fistula plug and fibrin glue are relatively ineffective treatments for fistula-in-ano. (1B)
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Minimally invasive approaches to treat fistula-in-ano that use endoscopic or laser closure techniques have reasonable short-term healing rates but unknown long-term fistula healing and recurrence rates. (2C)
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Rectovaginal Fistula

Nonoperative management is typically recommended for the initial care of obstetrical rectovaginal fistula and may also be considered for other benign and minimally symptomatic fistulas. (2C)
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A draining seton may facilitate resolution of acute inflammation or infection associated with rectovaginal fistulas. (1C)
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Endorectal advancement flap with or without sphincteroplasty is the procedure of choice for most patients with a rectovaginal fistula. (1C)
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Episioproctotomy may be used to repair obstetrical or cryptoglandular rectovaginal fistulas in patients with anal sphincter defects. (1C)
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A gracilis muscle or bulbocavernosus (Martius) flap is typically recommended for recurrent or otherwise complex rectovaginal fistula. (1C)
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Rectovaginal fistulas that result from colorectal anastomotic complications often require a transabdominal approach for repair. (1C)
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Completion proctectomy with or without colonic pull-through or coloanal anastomosis may be required to treat radiation-related or recurrent complex rectovaginal fistula. (2C)
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Anorectal Fistula Associated With Crohn’s Disease

Anorectal fistula associated with Crohn’s disease is typically managed with a combination of surgical and medical approaches. (1B)
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Asymptomatic fistulas in patients with Crohn’s disease typically do not require surgical treatment. (1C)
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Draining setons are typically useful in the multimodality therapy of fistulizing anorectal Crohn’s disease and may be used for long-term disease control. (1B)
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Symptomatic, simple, low anal fistulas in carefully selected patients with Crohn’s disease may be treated by lay-open fistulotomy. (2C)
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Endorectal advancement flaps and the LIFT procedure may be used to treat fistula-in-ano associated with Crohn’s disease. (1B)
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Patients with uncontrolled symptoms from complex anorectal fistulizing Crohn’s disease may require fecal diversion or proctectomy. (1C)
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Local administration of mesenchymal stem cells is a safe and effective treatment for selected patients with refractory anorectal fistulas in the setting of Crohn’s disease. (2B)
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Tables

Table 1. Parks classification of fistula-in-ano

Fistula type Description
Intersphincteric Crosses the internal sphincter and then has a tract to the perianal skin. Does not involve any external anal sphincter muscle.
Transsphincteric Tracks from the internal opening at the dentate line via the internal and external anal sphincters and then terminates in the perianal skin or perineum.
Suprasphincteric Courses superiorly into the intersphincteric space over the top of the puborectalis muscle and then descends through the iliococcygeus muscle into the ischiorectal fossa and into the perianal skin.
Extrasphincteric Passes from the perineal skin through the ischiorectal fossa and levator muscles and then into the rectum and lies completely outside the external sphincter complex.

Recommendation Grading

Overview

Title

Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula

Authoring Organization

Publication Month/Year

July 5, 2022

Document Type

Guideline

Country of Publication

US

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D012006 - Rectovaginal Fistula, D000071056 - Anorectal Malformations

Keywords

Anorectal Abscess, Fistula-in-Ano, Rectovaginal Fistula

Source Citation

Gaertner WB, Burgess PL, Davids JS, Lightner AL, Shogan BD, Sun MY, Steele SR, Paquette IM, Feingold DL; Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum. 2022 Aug 1;65(8):964-985. doi: 10.1097/DCR.0000000000002473. Epub 2022 Jul 5. PMID: 35732009.