Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula
Publication Date: December 1, 2016
Last Updated: March 14, 2022
RECOMMENDATIONS
Initial Evaluation of Anorectal Abscess and Anal Fistula
A disease-specific history and physical examination should be performed, emphasizing symptoms, risk factors, location, presence of secondary cellulitis, and fistula-in-ano. (1C)
312133
CT scan, ultrasound, MRI, or fistulography should be considered in patients with occult anorectal abscess, complex anal fistula, or perianal Crohn’s disease. (1B)
312133
Anorectal Abscess
Patients with acute anorectal abscess should be treated promptly with incision and drainage. (1C)
312133
Abscess drainage with concomitant fistulotomy may be performed with caution for simple anal fistulas. (2B)
312133
Antibiotics should be reserved for patients with anorectal abscess complicated by cellulitis, systemic signs of infection, or underlying immunosuppression. (2C)
312133
Treatment of Fistula-in-Ano
Simple fistula-in-ano in patients with normal anal sphincter function may be treated with fistulotomy. (1B)
312133
Endoanal advancement flaps are recommended for the treatment of fistula-in-ano. (1B)
312133
Simple and complex anal fistulas may be treated with ligation of the intersphincteric fistula tract (LIFT) procedure. (1B)
312133
A cutting seton may be used with caution in the management of complex cryptoglandular anal fistulas. (2B)
312133
The fistula plug is a relatively ineffective treatment for fistula-in-ano. (2B)
312133
Fibrin glue is a relatively ineffective treatment for fistula- in-ano. (2B)
312133
Treatment of Rectovaginal Fistulas
Nonoperative management is recommended for the initial management of obstetrical rectovaginal fistula and may also be considered for other benign and minimally symptomatic fistulas. (2C)
312133
A draining seton may be required to facilitate resolution of acute inflammation or infection associated with rectovaginal fistulas. (1C)
312133
Endorectal advancement flap, with or without sphincteroplasty, is the procedure of choice for most simple rectovaginal fistulas. (1C)
312133
Episioproctotomy may be used to repair obstetrical or cryptoglandular rectovaginal fistulas associated with extensive anal sphincter damage. (1C)
312133
A gracilis muscle or bulbocavernosus muscle (Martius) flap is recommended for recurrent or otherwise complex rectovaginal fistula. (1C)
312133
High rectovaginal fistulas that result from complications of a colorectal anastomosis often require an abdominal approach for repair. (1C)
312133
Proctectomy with colon pull-through or coloanal anastomosis may be required to repair radiation-related and recurrent complex rectovaginal fistula. (2C)
312133
Treatment of Perianal Fistula Associated with Crohn’s Disease
Asymptomatic fistulas in patients with Crohn’s disease do not require surgical treatment. (1C)
312133
Symptomatic, simple, low anal fistulas in patients with Crohn’s disease may be treated by fistulotomy. (1C)
312133
Loose setons are useful in the multimodality therapy of fistulizing perianal Crohn’s disease and may also be used for long-term disease control. (1C)
312133
Endoanal advancement flap, anal fistula plug, and the LIFT procedure may be used to treat fistula-in-ano associated with Crohn’s disease. (2B)
312133
Complex Crohn’s fistulas may require permanent diversion or proctectomy for uncontrollable symptoms. (1C)
312133
Recommendation Grading
Overview
Title
Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula
Authoring Organization
American Society of Colon and Rectal Surgeons
Publication Month/Year
December 1, 2016
Last Updated Month/Year
January 16, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Infant, Older adult
Health Care Settings
Ambulatory, Emergency care, Hospital, Long term care, Operating and recovery room, Outpatient
Intended Users
Medical assistant, nurse, nurse practitioner, physician, physician assistant
Scope
Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D003424 - Crohn Disease, D000038 - Abscess, D005402 - Fistula, D012006 - Rectovaginal Fistula
Keywords
Anorectal Abscess, Anal fistula, Fistula-in-Ano, Rectovaginal Fistula
Source Citation
Vogel, J. D., Johnson, E. K., Morris, A. M., Paquette, I. M., Saclarides, T. J., Feingold, D. L., & Steele, S. R. (2016). Clinical Practice Guideline for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Diseases of the Colon & Rectum, 59(12), 1117–1133. doi:10.1097/dcr.0000000000000733
Methodology
Number of Source Documents
267
Literature Search Start Date
December 1, 2015
Literature Search End Date
November 5, 2021