Initial Evaluation of Anorectal Abscess and Fistula

Anorectal Abscess

Anal Fistula

Rectovaginal Fistula

Anorectal Fistula Associated With Crohn’s Disease

Tables

Document Overview

Design and created by Guideline Central in participation with the American Society of Colon and Rectal Surgeons.

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

American Society of Colon and Rectal Surgeons

Publication Date: Jul 3, 2022

Page Last Updated: May 5, 2026

The GRADE system: grading recommendations

Grade	Description	Benefit vs. risk and burdens	Quality of supporting evidence	Implications
1A	Strong recommendation, High-quality evidence	Benefits clearly outweigh risk and burdens or vice versa	RCTs without important limitations or overwhelming evidence from observational studies	Strong recommendation, can apply to most patients in most circumstances without reservation
1B	Strong recommendation, Moderate-quality evidence	Benefits clearly outweigh risk and burdens or vice versa	RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or exceptionally strong evidence from observational studies	Strong recommendation, can apply to most patients in most circumstances without reservation
1C	Strong recommendation, Low- or very-low quality evidence	Benefits clearly outweigh risk and burdens or vice versa	Observational studies or case series	Strong recommendation but may change when higherquality evidence becomes available
2A	Weak recommendation, High-quality evidence	Benefits closely balanced with risks and burdens	RCTs without important limitations or overwhelming evidence from observational studies	Weak recommendation, best action may differ depending on circumstances or patients’ or societal values
2B	Weak recommendations, Moderate-quality evidence	Benefits closely balanced with risks and burdens	RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or exceptionally strong evidence from observational studies	Weak recommendation, best action may differ depending on circumstances or patients’ or societal values
2C	Weak recommendation, Low- or very-low quality evidence	Uncertainty in the estimates of benefits, risks and burden; benefits, risk, and burden may be closely balanced	Observational studies or case series	Very weak recommendations; other alternatives may be equally reasonable

Document Overview

Document Title: Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula

Authoring Society: American Society of Colon and Rectal Surgeons

Document Publication Date: Jul 3, 2022

Page Last Reviewed/Updated: May 5, 2026

Document Type: Guideline

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: journals.lww.com/dcrjournal/Fulltext/2022/08000/The_American_Society_of_Colon_and_Rectal_Surgeons.6.aspx?utm_source=press&utm_medium=press&utm_campaign=dcr_pr_072222

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.

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Scope: Management

Diseases/Conditions (MeSH)

D012006 - Rectovaginal Fistula

D000071056 - Anorectal Malformations

D012006 - Rectovaginal Fistula

D000071056 - Anorectal Malformations

Keywords: Anorectal Abscess, Fistula-in-Ano, Rectovaginal Fistula

Inclusion Criteria: Male, Female, Adult, Older Adult

Health Care Settings: Ambulatory, Hospital, Operating and Recovery Room, Outpatient

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Recommendation Development Processes & Methodology

Number of Source Documents: 267

Literature Search Start Date: Sunday, November 29, 2015

Literature Search End Date: Wednesday, November 3, 2021

Includes peer/external review process?: Yes

Includes public comment process?: No

Methodologist involvement?: Yes

Patient involvement?: No

Includes multi-disciplinary group?: Yes

Includes systematic review?: Yes

Grades quality of strength of evidence?: Yes

Grades quality of strength of recommendation?: Yes

Discloses funding source?: No

Discloses conflicts of interest?: Yes

Includes benefits/harms analysis with recommendations?: No

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.

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

Initial Evaluation of Anorectal Abscess and Fistula

Anorectal Abscess

Anal Fistula

Rectovaginal Fistula

Anorectal Fistula Associated With Crohn’s Disease

Tables

Table 1. Parks classification of fistula-in-ano

The GRADE system: grading recommendations

Document Overview

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Recommendation Development Processes & Methodology