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)
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CT scan, ultrasound, MRI, or fistulography should be considered in patients with occult anorectal abscess, complex anal fistula, or perianal 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 with caution for simple anal fistulas. (2B)
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Antibiotics should be reserved for patients with anorectal abscess complicated by cellulitis, systemic signs of infection, or underlying immunosuppression. (2C)
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Treatment of Fistula-in-Ano
Simple fistula-in-ano in patients with normal anal sphincter function may be treated with fistulotomy. (1B)
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Endoanal advancement flaps are recommended for the treatment of fistula-in-ano. (1B)
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Simple and complex anal fistulas may be treated with ligation of the intersphincteric fistula tract (LIFT) procedure. (1B)
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A cutting seton may be used with caution in the management of complex cryptoglandular anal fistulas. (2B)
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The fistula plug is a relatively ineffective treatment for fistula-in-ano. (2B)
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Fibrin glue is a relatively ineffective treatment for fistula- in-ano. (2B)
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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)
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A draining seton may be required to 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 simple rectovaginal fistulas. (1C)
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Episioproctotomy may be used to repair obstetrical or cryptoglandular rectovaginal fistulas associated with extensive anal sphincter damage. (1C)
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A gracilis muscle or bulbocavernosus muscle (Martius) flap is recommended for recurrent or otherwise complex rectovaginal fistula. (1C)
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High rectovaginal fistulas that result from complications of a colorectal anastomosis often require an abdominal approach for repair. (1C)
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Proctectomy with colon pull-through or coloanal anastomosis may be required to repair radiation-related and recurrent complex rectovaginal fistula. (2C)
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Treatment of Perianal Fistula Associated with Crohn’s Disease
Asymptomatic fistulas in patients with Crohn’s disease do not require surgical treatment. (1C)
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Symptomatic, simple, low anal fistulas in patients with Crohn’s disease may be treated by fistulotomy. (1C)
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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)
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Endoanal advancement flap, anal fistula plug, and the LIFT procedure may be used to treat fistula-in-ano associated with Crohn’s disease. (2B)
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Complex Crohn’s fistulas may require permanent diversion or proctectomy for uncontrollable symptoms. (1C)
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Recommendation Grading
Disclaimer
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
August 10, 2023
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