ANZ J. Surg.

2005; 75: 6472

REVIEW ARTICLE
REVIEW ARTICLE

ANAL ABSCESSES AND FISTULAS

MATTHEW J. F. X. RICKARD
Department of Colorectal Surgery, Concord Hospital, Sydney, New South Wales, Australia
Anal abscesses and fistulas are a common part of surgical practice. Most abscesses simply need to be drained and most fistulas can be
safely laid open. Excessive probing should not be attempted when draining abscesses as this may lead to iatrogenic fistulas. A small
percentage of fistulas are complex and very challenging to manage. Management involves an accurate diagnosis and a balance
between eradication of the fistula and maintenance of continence. A decision should be made, based on clinical evaluation and anal
ultrasound (if available), whether the fistula can be laid open. If it cannot be laid open, a loose seton is placed and the sepsis is
allowed to settle. Once the sepsis is quiescent, a definitive repair can be attempted. There are various techniques available including
rectal advancement flap, fibrin glue and cutaneous flaps all of which are discussed.
Key words: anal fistula, peri-anal abscess.
Abbreviations: AIN, anal intraepithelial neoplasia; ATZ, anal transitional zone; ES, external sphincter; EUA, examination

under anaesthetic; EUS, endo-anal ultrasound; IS, internal sphincter; MRI, magnetic resonance imaging; PPV, positive predictive value; RAF, rectal advancement flap; RCT, randomized controlled trial.

INTRODUCTION
Anal abscesses and fistulas are a common surgical condition.
Management of the majority of anal abscesses and fistulas is
straightforward and is based on a sound knowledge of the
anatomy of the anorectum and adherence to established surgical
principles. A small percentage of anal abscesses and fistulas are
complex and very challenging to manage surgically. The joint
aims of maintaining perfect continence and curing the fistula are
often difficult to achieve.

ANATOMY
An understanding of the anatomy of the anal canal is essential for
the appropriate management of anal fistulas. The external sphincter (ES) is a continuation of the pelvic floor musculature. The
internal sphincter (IS) is a continuation of the inner circular
muscle layer of the lower rectum (Fig. 1). These muscle layers are
easily appreciated on endo-anal ultrasound (EUS). The IS appears
as a hypo-echoic ring. The ES is identified by first identifying the
puborectalis sling at the anorectal junction. This is hyper-echoic
and U-shaped. Below this the ES commences when the open end
of the U begins to close to form a complete ring of muscle.14
The mucocutaneous junction is the site of the dentate line (the
term pectinate line should be discarded).5 The epithelium of the
anal canal is mucosa above the dentate line and stratified nonkeratinized squamous epithelium below. The dentate line is the
site of the anal valves. Proximal to each anal valve is an anal
crypt or sinus, which macroscopically appears as a small pit. The
anal glands, which lie in the intersphincteric plane, empty into
these anal crypts. For a distance of 520 mm (varying with age)
above the dentate line, the mucosa is cuboidal and is known as
M. J. F. X. Rickard MB BS, MMed (ClinEpi), DipPaed, FRACS.
Correspondence: Dr Matthew Rickard, Department of Colorectal Surgery,
Concord Hospital, Sydney, NSW 2137, Australia.
Email: mjfxr@ozemail.com.au
Accepted for publication 18 August 2004.

the anal transitional zone (ATZ).6,7 This area is thought to be

important for discrimination between flatus and faeces. Above
the ATZ, the mucosa becomes columnar with typical goblet
mucus secreting cells.

AETIOLOGY
The cryptoglandular theory of Eisenhammer and Parks is now
widely accepted, although there have been very few subsequent
studies to confirm or refute it. Eisenhammer proposed that an
intramuscular anal gland became infected and because of subsequent infective obstruction of its connecting duct, it was unable to
drain spontaneously into the anal canal.8 Parks found cystic dilatation of anal glands in eight of 30 consecutive cases of anal fistula. He attributes this to either acquired duct dilatation or a
congenital abnormality and suggested that it was a precursor to
infection within a mucin-filled cavity.9 Infection begins in the
intersphincteric plane. If it tracks downwards in the intersphincteric plane, a perianal abscess forms. If it tracks upwards in the
intersphincteric plane, a high intersphincteric abscess or supralevator abscess might form. Sepsis that tracks across the ES will
result in an ischio-rectal abscess. If this then extends upwards
across the levator plate, it may form a supralevator abscess
(Fig. 2). Horseshoe abscesses form from circumferential spread.
This is most common in the ischiorectal plane, but can occur in
the perianal and supralevator planes.10
It has been suggested that most high anal fistulas and most
degrees of incontinence represent iatrogenic and therefore avoidable complications of abscess or fistula surgery.11

CLASSIFICATION
Initial classifications were made by Milligan and Morgan,12
Steltzner,13 Goligher,14 and Eisenhammer15. These were refined
by Parks et al. and his classification intersphincteric, transsphincteric, supra-sphincteric and extra-sphincteric (Fig. 3) is
now the most widely used and taught.16 Extensions (secondary
tracks) might occur in the intersphincteric plane, the ischiorectal
fossa and the pararectal (supralevator) space.

ANAL ABSCESSES AND FISTULAS

65

Fig. 1. Anal canal anatomy.

Fig. 2. Supralevator extensions.

There are limitations to Parks classification. Superficial fistulas

are not classified because of the emphasis on the intersphincteric
plane. These are common and make up around 16% of one series.17
The lowermost fibres of the ES curve in under the distal edge of the IS
and on EUS the lower third of the anal canal has no IS. In the authors
experience, true intersphincteric fistulas, as classified by Parks, do not
occur. Even very low fistulas cross some of these lowest fibres of the
external sphincter and are, hence, trans-sphincteric.
The best treatment for an anal fistula is to lay it open. Obviously if this involves cutting a large amount of anal sphincter

this will cause incontinence. Bennett in 1962 said: It is poor

consolation for the fastidious patient who, after 17 weeks off
work for treatment of his horseshoe fistula, finds that his underclothes are stained brown instead of yellow, even though his
fistula is healed.18
A more clinically useful classification is whether or not a
fistula can be laid open. This would be based on clinical and EUS
findings and depends not just on the type of fistula, but also the
sex of the patient and the extent of any pre-existing sphincter
abnormalities.

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RICKARD

ANORECTAL ABSCESS
Presentation of anorectal abscesses
Anorectal abscesses usually present with local pain and swelling.
Presenting features vary depending on the site of the abscess and
some patients may present simply with a pyrexia of unknown
origin. Abscesses can be classified as perianal, ischiorectal, intersphincteric, or supralevator (Fig. 4).
Perianal abscesses usually present with a tense, tender erythematous swelling of short duration without any systemic signs
of toxicity. Ischiorectal abscesses often have a long history of
throbbing pain and can be associated with systemic toxicity.
Intersphincteric abscess presents with severe rectal pain and can
be mistaken for an anal fissure on history. There is often associated pyrexia (which should not occur in a simple fissure). Digital
rectal examination is extremely painful but might reveal a tender
nodule towards the upper end of the anal canal. A supralevator
abscess presents with pelvic pain and constitutional symptoms. It
might represent a true pelvic abscess from intra-abdominal
pathology or an intersphincteric or ischiorectal abscess that has
tracked upwards. Digital rectal examination may reveal a boggy
tender swelling in the rectum.19
Management of anorectal abscesses
Abscesses require surgical drainage under general anaesthesia.
An intersphincteric abscess is readily identifiable on EUS and can
usually be drained endo-anally by excising a small disc of internal sphincter directly over the abscess. A supralevator abscess
that is an extension in the intersphincteric plane can often be
drained by opening into the intersphincteric plane in the upper
anal canal and then dissecting in the intersphincteric plane up to
the abscess. The abscess can be drained via this track and a small
mushroom tipped catheter (de pezzer) can be left in the cavity for
34 days to prevent recurrence.

Perianal and ischiorectal abscesses are much more accessible

and easy to drain. A supralevator extension of an ischiorectal
abscess can be drained through the ischiorectal fossa. Whether
an internal opening should be sought for at the time of draining
an anorectal abscess is a source of debate. The prevalence of anal
fistula formation ranges from 5 to 83%.2023 Subsequent fistula
formation is more likely with a perianal abscess than an ischiorectal abscess or if the abscess is complicated, e.g., horseshoe
abscess.22,24
There have been six randomized clinical trials (RCT)23,2529
comparing immediate and delayed treatment of associated fistula
tracks. The first five of these were subjected to a crude meta-analysis. The findings were that if the fistula track is not sought out and
treated when the abscess is drained, patients are 13 times (5.447
95%CI) more likely to have persistent problems with sepsis. However, if the track is sought out and treated there is an increased
incidence of incontinence (odds ratio 0.36 (0.130.93).30
The sixth and most recent trial includes 100 patients in each
arm of the study.23 In this series an anal fistula was identified in
83% of the group of patients where it was sought and treated
(group A). In the group of patients where only drainage of the
abscess was performed (group B), 29% went on to develop fistulas. In groups A and B the overall incontinence rate at 1 year was
6 and 0%, respectively. The conclusion of the paper was that
drainage of anal abscess with fistulotomy can be safely performed in cases of subcutaneous, intersphincteric, or low transsphincteric fistulas with minimal recurrence. However, if the
raw data is re-analysed, patients in group A were 2.8 times more
likely to have a fistula (relative risk 2.8 (2.13.9 95% CI),
P < 0.0001) and infinitely more likely to have continence problems (relative risk = infinity, P = 0.03). The obvious interpretation is that fistulas are present in the majority of cases of
anorectal abscess formation, but that many resolve spontaneously
such that aggressive early identification and treatment may be
unnecessary and lead to poorer outcomes.

Fig. 3. Parks classification.

ANAL ABSCESSES AND FISTULAS

67

Fig. 4. Abscess positions.

A reasonable approach is to inspect the anal canal with a suitable retractor before the abscess is drained. If moderate pressure
on the abscess leads to obvious extrusion of pus into the anal
canal at a readily identifiable internal opening, the abscess can be
drained and a Seton placed along the fistula track. It is always
safer to place a Seton in the track rather than lay open the track,
as the extent of sphincter involvement is difficult to define in the
presence of acute inflammation. If there is no obvious internal
opening with this simple manoeuver, the abscess should simply
be drained with an incision parallel with the anal canal (less likely
to cut through the lower most fibres of the ES). No attempt
should be made to look for a fistula with probes. In reality, inexperienced surgeons often perform this operation. Therefore, it
should be kept as simple as possible. It is the authors practice to
use a 2030 mm incision only, break down the loculations digitally and place a de pezzer catheter into the cavity. The drain is
left until there is minimal purulent drainage, which may vary
from a few days to several weeks.

ASSESSMENT OF ANAL FISTULA

In 1900 Goodsall and Miles outlined five essential points in the
assessment of fistulas.31 The principles remain unchanged.
The location of the internal opening (a fistula can never be
eradicated if this is not identified)
The location of the external opening
The course of the primary track
The presence of secondary extensions
The presence of other diseases complicating the fistula

thumb when performing digital rectal examination. Any clinical

abnormalities of the anal sphincter, such as poor resting and/or
squeeze tone and deficiencies from obstetric or iatrogenic trauma
should be noted. No attempt should be made to pass probes in
an awake patient as it is very unpleasant and might create false
tracks. If there is no abscess formation requiring drainage, further
assessment either by EUS or examination under anaesthetic
(EUA) depending on available facilities is recommended.
Goodsall and Miles so-called rule states that fistulas with an
external opening lying above a horizontal line drawn through the
centre of the anal canal, with the patient in lithotomy position,
usually drain directly into the anal canal. Fistulas lying below this
horizontal line usually drain to the midline posteriorly.31 Like all
rules, there are exceptions. Cirocco and Reilly put the rule to the
test in 1992. They reported a predictive accuracy of 90% for posterior fistulas, but only 49% of anterior fistulas obeyed the rule.32
Conversely, Gunawardhana and Deen, when comparing hydrogen peroxide installation with Goodsalls rule, found a predictive
accuracy for posterior and anterior fistulas of 41 and 72%,
respectively.33
Differential diagnoses should be considered in every case.
Hidradenitis suppurativa, tuberculosis, Bartholins abscess, actinomycosis, anal fissure, ulceration associated with Crohns disease, sexually transmitted diseases, and a low pilonidal sinus are
all possible differential diagnoses. A more important distinction
is the differentiation between a chronic abscess and a perirectal
dermoid cyst or a sacrococcygeal teratoma. If these lesions are
inadvertently opened total excision may prove difficult and a
sacrococcygeal fistula might develop, which is often impossible
to eradicate.34

Clinical assessment
In reality, the prevalence of fistula formation after drainage of an
anorectal abscess is around 30%. Persistent drainage from the
drainage site and/or recurrent abscess formation are usual indications that a fistula is present. The external opening is usually clear
and is at the site of previous drainage or at the site of spontaneous
drainage. The fistula track can often be felt between finger and

Imaging
In practice, most low fistulas do not require imaging. Assessment
and management is based on clinical evaluation and the findings
at EUA. In the current medico-legal environment an objective
assessment of the extent of muscle involved in a fistula is helpful
prior to laying it open. How this is done depends on the local

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RICKARD

availability of imaging techniques. It is the authors practice to

perform an EUS on all anal fistulas. This is performed either in
theatre under general anaesthesia or in the clinic without sedation.
Endo-anal ultrasound
There are three criteria for identification of the internal opening
on EUS: (i) contact of the internal sphincter by the intersphincteric track (positive predictive value (PPV) of 80%); (ii) an apparent defect of the internal sphincter (PPV 79%); and (iii) a defined
subepithelial track associated with a localized sphincter defect
(PPV 94%).35
The overall sensitivity using all three of these signs is 94%
with a specificity of 87% and a PPV of 81%. The gas reflections
from hydrogen peroxide highlight the track and may help to
locate the site of the internal opening.3640
Gold et al. studied interobserver and intraobserver agreement
in assessing the anal sphincter and found interobserver agreement
to be very good (kappa = 0.84).41 Conversely, Robinson described error and variation in image interpretation as the Achilles
heel of radiology. The human eye and brain have failed to keep
up with technological advances.42
One of the limitations of EUS is the difficulty distinguishing
recrudescent sepsis from burnt-out fibrotic tracks in complicated
disease.
Magnetic resonance imaging
The advantages of magnetic resonance imaging (MRI) include
multiplanar imaging and high soft-tissue differentiation to
show the track system in relation to underlying anatomy in a
projection relevant to surgical exploration.43 The accuracy of
MRI has been confirmed by comparison with surgery.4447 It is
especially helpful in assessing complex fistulas secondary to
Crohns disease.48,49
Fistulography
Fistulography is certainly not the first line investigation. False
positive results for rectal openings and high extensions have been
reported50 and might lead to inappropriate surgery. Fistulography
is an inaccurate, unreliable and possibly harmful procedure.51
Chronic tracks may be patent, but many acute tracks are actually
just columns of inflamed granulation tissue without a patent
lumen. Contrast injection therefore may show only part of the
track system.43 Nevertheless, for complex fistulas, particularly
those where repeated examination under anaesthesia has been
unsuccessful in defining the course of the track, fistulography
may be helpful in combination with either MRI and/or EUS.
Other investigations
Manometry
Manometry does not need to be done routinely, but might be
helpful on occasions to objectively assess sphincter function if a
decision is being made as to whether or not to lay open a fistula.
If the resting pressure appears abnormal clinically, manometry
may be used to confirm this clinical impression.
Examination under anaesthesia
If only an assessment is planned it is often more helpful to
perform the examination under light general anaesthetic without
muscle relaxation. If a definitive procedure is planned based on
EUS or previous EUA, muscle relaxation may be used. Usually

the lithotomy position is adequate. (For a rectal advancement flap

on an anterior fistula the prone position should be used.) Careful
palpation will usually identify induration along the fistula track.
Pressure over the indurated area might lead to extrusion of pus
through the internal opening. Traction on the external opening
sometimes defines the internal opening.
A probe can be inserted through the external opening (prograde passage).34 Most often, this probe will easily pass along the
track through the internal opening into the anal canal. A soft
blunt-ended probe should be used. (Lockhart-Mummery fistula
probes should probably be avoided as their tips are sharp.) A
probe passed progradely that follows a course parallel to the anal
canal is either in a secondary track from a transphincteric fistula
or a long intersphincteric fistula. Hydrogen peroxide can be
inserted via the external opening to identify the internal opening.37,52 Probes with curves of varying degrees can be used to
identify the internal opening. Anal crypts can be mistaken for
internal openings, but these are very shallow. If available, an
EUS performed during EUA can be very helpful in outlining the
track and identifying the internal opening.

TREATMENT OF ANAL FISTULA

The objectives of management have been outlined by Finlay:53
to define the anatomy of the fistula
to drain any associated sepsis
to eradicate the fistula track
to prevent recurrence
to preserve continence and sphincter integrity
After full assessment it is the authors practice to either lay
open the fistula or place a Seton and then re-assess after
23 months. At this time the fistula may now be able to be laid
open or a rectal advancement flap can be performed.
When can a stula be laid open?
The best treatment, in terms of absolute cure, is to lay open the
fistula. It is usually clear that a very high fistula should not be laid
open and that a very low fistula can be laid open without any
functional sequelae. The low and mid trans-sphincteric fistulas
cause the most concern and difficulty in deciding whether to lay
open or to place a Seton. If in doubt, always place a loose Seton,
especially if a full discussion with the patient regarding possible
complications of muscle division has not taken place.
As a general rule of thumb, a fistula can be laid open if it
encompasses half of the external sphincter bulk posteriorly in a
man, one third of the sphincter bulk anteriorly in a man, one third
of the sphincter bulk posteriorly in a woman and never anteriorly
in a woman. However, this decision needs to be individualized
based on the condition of the sphincter. This will be affected by
previous obstetric trauma, previous perianal operations (e.g.,
lateral sphincterotomy) and congenital abnormalities. It is essential to enquire regarding the above when taking the history.
Lay open technique (stulotomy)
The majority of anal fistulas are successfully treated by this technique with little in the way of disturbed continence, however, this
risk should be discussed with every patient. The lithotomy position is adequate to simply lay open a fistula. A Parks anal or HillFerguson retractor is used to visualize the anal canal. The track is
defined with a blunt ended probe. The tissue overlying the probe

ANAL ABSCESSES AND FISTULAS

69

The term seton is derived from the Latin word seta meaning
bristle. Setons may be loose or cutting. Thin silastic tubing (vessel loop) is commonly used. Another option is monofilament
nonabsorbable nylon suture. When a loose seton is placed it is
better to tie the ends of the seton parallel to each other with heavy
silk (Fig. 5). When the seton is tied to itself, the knot is bulky and
unpleasant for the patient. Some surgeons will lay open the lateral
portion of the fistula track so that the seton encompasses only the
sphincter bulk.60 This may not be necessary, as eventual eradication of the fistula depends only on elimination of the internal
opening. It is the authors practice to simply place the seton along
the track. At the time of placement, any extra tracks or undrained
cavities can be drained with a de pezzer catheter, which is left in
place for a few days or weeks.
Occasionally, when a seton has been present for 23 months,
it may be apparent that the fistula can be safely laid open. It has
been suggested that this is because of fibrosis associated with the
fistula.61,62 It is more likely that it is simply that any associated
inflammation has settled and a more accurate assessment of the
fistula can be made.
Setons can be used long-term and may be the preferred option
in fistulas associated with Crohns63 disease and those that have
recurred despite many attempts at repair.

Patients are given a full bowel preparation prior to the procedure. For anterior fistulas the prone jack-knife position is used.
For posterior and lateral fistulas lithotomy is adequate. First
the flap is marked out with diathermy. It commences 510 mm
below the internal opening and around 1015 mm either side of
the internal opening. The intersphincteric plane is infiltrated
with a 1:400 000 solution of adrenaline. Mobilization should
begin laterally away from the track on either side where the
planes are virginal. The intersphincteric plane is identified and
only then is the dissection continued towards the track. The flap
should be raised proximally to the low rectum and should be
under no tension when sutured. The portion of the flap containing the internal opening is excised and the flap is secured with
sutures (3/0 PDS) encompassing the internal sphincter in the flap
and the internal sphincter of the remaining anal canal. There is
no need to do anything to the external opening; however, a small
drain (infant feeding tube) should be placed through the external
opening to lie underneath the flap and should be removed after
23 days.
The success rate for RAF varies in the literature from 29 to
95%.6575 A realistic estimate of success rate from more recent
series is 6070%.74,75 In a recent series from the Cleveland Clinic,
USA the overall primary success rate was 64%. When patients
with Crohns disease were excluded, the success rate rose to 77%.
As would be expected, the success rate decreases with each successive attempt.65,75 It is possible that the success rate might be
improved if RAF is combined with application of fibrin glue to
the track and the bed of the flap.
The functional results after RAF appear good. Finan76 and
Kreis et al.77 report no change in anal manometry or rectal
compliance. Most papers report no deterioration in continence,65,7173,76 however, Mizrahi et al.78 report a 9% incidence
of deterioration in continence. Schouten et al.75 report that of
26 patients with normal continence preoperatively, 38% reported
flatus incontinence and 12% faecal incontinence.

Advancement ap

Fibrin glue

An advancement flap should be considered if a fistula cannot be

laid open. It should only be done when all signs of acute sepsis
have settled.64 The term mucosal advancement flap is a misnomer, as the flap is raised in the intersphincteric plane and
includes both mucosa and IS. It is better described as rectal
advancement flap (RAF).

Fibrin tissue adhesive has been used as a surgical sealant since

the early 1940s.79 In the last 1015 years there have been many
reports of the use of Fibrin glue in anal fistulas.8091 The success
rate varies from 14 to 85%. This wide variation is explained by
utilization of different types of glue, different techniques of insertion, different types of fistulas and different lengths of follow-up.
The technique is easy and no division of muscle occurs. The only
potential disadvantage is that if the treatment fails, sepsis might
recur and the track might become more complex.89 A randomized
controlled trial at Oxford found no advantage for fibrin glue over
fistulotomy for simple fistulas. Fibrin glue healed more complex
fistulas than conventional treatment (which included RAF) with
higher patient satisfaction. In this trial 13 of the 16 patients
having conventional treatment of complex fistulas had loose
setons and healing would not be expected with the seton still in
place.88
All acute sepsis should have settled and the track should be
debrided prior to placement of the glue. It appears to work better
in more complex fistulas and those with longer tracks. It is not
good for short recto-vaginal fistulas. The most recent publications have reported only moderate success (14%87 and 33%91).
Enthusiasm for fibrin glue treatment of anal fistulas has increased
recently in Australia with the release of an easy to use product,
although anecdotal results have not been encouraging.

is divided along its entire length. The granulation tissue along the
track is curetted. Any overhanging edges of skin can be excised
with diathermy. Haemostasis is achieved with diathermy. Any
extra tracks or undrained collections should also be opened. The
wound is packed loosely with saline soaked gauze and this is
removed when the patient washes the next day. Further packing
is usually painful and mostly unnecessary. Recurrence after this
technique ranges in the literature from 0 to 9% and disturbance in
continence varies from 0 to 33%.17,21,24,5459
Seton

Fig. 5. Loose seton.

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RICKARD

IF NOTHING IS WORKING

Other options
flap92

flap93),

Cutaneous flaps (island

or V-Y
which involve
mobilization of skin from the anal verge and transposition of this
into the anal canal, have been described with good results. This is
surprising, given that biomechanically the forces of defecation
are directed to dislodging the flap rather than compressing it, as is
the case with RAF. This technique should be considered in fistulas with a very low internal opening, which cannot be laid open
and a RAF would leave mucosa outside the anal canal.
Cutting setons are still used by some, but lead to a keyhole
deformity in the anal canal; they are poorly tolerated because of
pain and are associated with high rates of incontinence.94,95
Chemical setons utilizing ayurvedic medicated thread (Kshara
sutra) are described in the Indian literature. This is a variation of
the cutting seton and involves a seton soaked in a caustic solution
of three herbs. The method of action is unknown, but alkaline pH
is critical. The herbs possess anti-inflammatory, antibacterial,
and wound-healing properties. In a randomized trial comparing
this method with conventional methods involving 500 patients,
chemical setons obtained better results than conventional methods
(recurrence 4% vs 11%, P = 0.03).96
A Martius flap involves mobilization of the fibro-fatty pad in
the labia. This can be used in recto-vaginal fistula to fill the
defect after mobilization of both rectum and vagina on either side
of the fistula.97
Long-term setons are very well tolerated and often used in
Crohns disease and recurrent fistulas.

EXTRA-SPHINCTERIC FISTULAS
The primary pathology in a true extra-sphincteric fistula is intraabdominal. Common causes are diverticular disease, enteric
Crohns disease, malignancy and radiation damage to the bowel.
An abdominal approach is required.

FISTULAS ASSOCIATED WITH

CROHNS DISEASE
Full discussion of this topic is beyond the scope of the present article.
Usually a long-term seton is the safest option. This reduces perianal
drainage and pain without damaging the sphincter and minimizes the
risk of future abscesses arising from the fistula track.63 In the presence of active proctitis, any definitive surgery is very unlikely to be
successful. Without proctitis, definitive surgery (laying open low fistulas, RAF for high fistulas) can be attempted. Success rates will still
be lower than in patients without Crohns disease.98
Infliximab is a murine chimeric monoclonal antibody against
tumour necrosis factor-. It is the only medical treatment proven to
lead to a reduction in the number of perianal fistulas in patients
with Crohns disease.99 However, in practice, recurrence after cessation is common. There is emerging evidence that in patients with
setons in place who are undertaking a course of Infliximab for
enteric Crohns disease, it may be worthwhile to simply remove the
seton during the second course of Infliximab treatment.100

ANORECTAL SEPSIS IN HIV

As a general principle, anorectal sepsis in an HIV positive patient
should be treated along the same principles as anorectal sepsis in
Crohns disease. Any tissue that is removed should be submitted
to histological analysis as the prevalence of anal intraepithelial
neoplasia (AIN) is high in this situation.101

It might be appropriate to place a loose seton and plan to leave

this in long-term. These are surprisingly well tolerated. Consider
a pelvic cause for the fistula. Is it, in fact, an extra-sphincteric fistula? Perform an abdomino-pelvic computed tomography scan
and a fistulogram. Is it not a fistula, but something very uncommon such as an infected epidermoid cyst?

SUMMARY
Most abscesses simply need to be drained and most fistulas can
be safely laid open. An understanding of the anatomy of the anal
canal and the aetiology of peri-anal abscesses and anal fistulas
is essential. Abscesses require surgical drainage under general
anaesthesia. Intersphincteric and supralevator abscesses may be
difficult to identify clinically. Anal ultrasound or MRI can be
used in these situations depending on local availability and expertise. When an abscess is drained no attempt should be made to
probe the cavity as this can lead to iatrogenic fistulas. If an associated fistula is obvious even without probing a seton should be
placed and left until the sepsis and associated inflammation and
swelling has settled.
It is usually clinically evident with very low and very high fistulas whether or not laying open is appropriate. Laying open a fistula
is the most successful method of treatment and in most situations
this can be done safely without any disturbance of continence. In
mid level fistulas radiological assessment (usually with anal
ultrasound) complements clinical examination and an objective
assessment of the extent of sphincter involvement can be made. If
it is not appropriate to lay open the fistula, another form of definitive repair will be required. A rectal advancement flap is a reasonable approach in this situation. The success rate for this technique is
around 6070% and functional results are good. If it fails it can be
repeated, albeit with a lower success rate. When multiple attempts
at repair have failed a long-term seton may be the best option.

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