CHAPTER
156 Anal Sepsis and Fistula
Lucas A. Julien
l Jennifer S. Beaty
A
norectal suppurative disease may manifest itself in
an acute or a chronic setting. Anal sepsis (abscess)
represents the acute manifestation, and anal
fistula represents the chronic form of the suppurative
process. In its simplest form, an anal fistula represents a
communication between an internal opening in the anal
canal and an external opening through which an abscess
has drained. A fistula and abscess may coexist or be asso-
ciated with atypical internal openings and multiple tracts
that result in a complex suppurative process.
ETIOLOGY
Foreign bodies, malignancy, trauma, tuberculosis, actino-
mycosis, leukemia, postoperative infection, inflammatory
bowel disease, and simple skin infections have long been
associated with anal sepsis. Recently, an association
between anal abscess-fistula and history of concurrent or
recent cigarette smoking has been demonstrated.1 This
association diminishes as the history of cigarette smoking
grows more remote. Most anal sepsis, however, is related
to an infection of the anal glands and ducts. Fecal bacte-
rial plugging of the ducts leads to obstruction and sub-
sequent abscess formation. This process represents the
cryptoglandular theory of anal sepsis. Robinson,2 Seow,3
and their associates have suggested that the description
of the anal glands by Chiari in 1878 and the subsequent
histologic studies of Parks in 1961 contributed to the
acceptance of the cryptoglandular theory as the most
common cause for anal sepsis.
CLASSIFICATION
ANORECTAL ABSCESSES
Anorectal abscesses are classified according to the peri-
rectal space involved in the suppurative process; these
include the perianal, ischiorectal, intersphincteric, sub-
mucosal, deep postanal, and supralevator spaces (Figure
156-1). A given suppurative process may involve multiple
perirectal spaces. For example, the classic “horseshoe”
abscess originates in an infected gland in the posterior
midline extending through the intersphincteric and
deep postanal spaces to one or both of the ischiorectal
spaces. A condition known as “floating anus” may occur
with circumanal spread of intersphincteric, supralevator,
or ischiorectal collections.
It is difficult to accurately assess the incidence of
various abscesses because of the numerous classifications
and referral patterns reflected in large series.4-8 However,
perianal abscesses account for the largest number in
most series (Table 156-1).
1914
l Alan G. Thorson
ANAL FISTULA
Historically, anal fistulas have been classified in many
different ways. However, the Parks classification intro-
duced in 1976 is the most comprehensive and widely
used. It is derived from the cryptoglandular hypothesis
and has therapeutic implications. Parks classified fistulas
into four main subgroups according to the course taken
by the main tract: intersphincteric, transsphincteric,
suprasphincteric, or extrasphincteric.9 Each category can
be further subclassified based on associated secondary
tracts and other anatomic details (Figure 156-2). As with
abscesses, the incidence of various fistulas is difficult to
quantify. Overall, however, intersphincteric fistulas seem
to predominate (Table 156-2).
DIAGNOSIS
ANORECTAL ABSCESS
History
Symptoms common to all abscesses include the slow,
gradual onset of pain, increasing in intensity to the sensa-
tion of pressure and fullness. This is a constant, nonre-
lieving sensation. These symptoms should always lead to
the consideration of an abscess even in the absence of
obvious physical findings (hidden abscesses). Approxi-
mately 20% to 33% of all patients will report a history of
a previous episode of anorectal sepsis.8,13
Physical Examination
The physical findings associated with anorectal abscesses
vary depending on the anatomic location of the abscess.
The presence of pus in any of the perianal and perirectal
spaces may be confirmed with needle aspiration. An
examination under general anesthesia may be necessary
to confirm the diagnosis.
PERIANAL ABSCESS
Localized swelling, hyperemia, induration or fluctuance,
and tenderness are present adjacent to the anus. A puru-
lent discharge may be present if spontaneous drainage
has occurred. Although there usually are no systemic
symptoms, the patient may have fever or malaise or be
acutely ill.
ISCHIORECTAL ABSCESS
Although small collections may present with discrete
localized swelling, more commonly there is a large, ery-
thematous, and indurated mass in the buttock. Large
volumes of purulent material may accumulate in the
ischiorectal space. Fever and leukocytosis are common
but not always present. A large ischiorectal abscess
 Anal Sepsis and Fistula CHAPTER 156 1915

FIGURE 156-1 Classification of anorectal abscesses by location. A, Coronal view. B, Sagittal view.
1916 SECTION IV Colon, Rectum, and Anus

TABLE 156-1 Incidence of Anorectal Abscess by Location

NO. OF PATIENTS TOTAL

McElwain Scoma Vasilevsky and Schouten and van Ramanujam No. of
Abscess Locations et al 4 et al 7 Gordon 8 Vroonhoven 6 et al 5 Patients %
Perianal 456 174 20 — 437 1087 44.8
Submucosal 3 — — — — 3 0.1
Intermuscular 541 30 — — 59 630 26
Intersphincteric — — 18 28 219 265 11
Transsphincteric — — — 30 — 30 1.2
Ischiorectal — 14 63 — 233 310 12.8
Supralevator — 9 2 — 75 86 3.6
Retrorectal — 5 — — — 5 0.2
Unclassified — — — 8 — 8 0.3
Total 1000 232 103 66 1023 2424 100

frequently represents a horseshoe extension (see later).
A source in the posterior midline should be sought.
INTERSPHINCTERIC AND SUBMUCOUS ABSCESS
The intersphincteric and submucous abscesses usually
present with no visible evidence of sepsis because these
“hidden abscesses” are confined to the anal canal. Owing
to the patient’s discomfort, a digital rectal examination
is not always possible. In this situation, an examination
under general anesthesia is warranted to identify the
abscess.
SUPRALEVATOR ABSCESS
Supralevator abscess may occur as an upward extension
of a collection in the distal anal canal, usually an inter-
sphincteric abscess, or as a true pelvic abscess secondary
to intraabdominal or pelvic pathology. Possibilities
include appendicitis, diverticulitis, pelvic inflammatory
disease, or ruptured viscus. The patient may be systemi-
cally ill. A pelvic mass may be identified by rectal or
vaginal examination.
POSTANAL ABSCESS AND HORSESHOE EXTENSION
Transsphincteric extension of an intersphincteric abscess
in the posterior midline leads to the accumulation of
purulent material in the deep postanal space. This space
is difficult to evaluate clinically, making these the second
type of hidden abscess. Inspection does not reveal any
inflammatory skin changes because the abscess is deep.
There may be tenderness posterior to the anus but ante-
rior to the coccyx. The collection may be apparent only
by needle aspiration or with an examination under
general anesthesia. A horseshoe abscess is the result of a
direct extension of a postanal abscess into the ischiorec-
tal space (see Ischiorectal Abscess). It may be unilateral
or bilateral.
ANORECTAL FISTULAS
History
Most patients with a fistula-in-ano have a previous history
of anorectal suppuration. The patient usually presents
with complaints of intermittent or persistent purulent or
serosanguineous drainage from an external opening in
the perianal area. Symptoms classically consist of a
buildup of pain, slight fever, and pain on defecation fol-
lowed by mucopurulent drainage and abatement of the
pain. Pruritic symptoms may be present because of skin
irritation associated with the chronic discharge.
Physical Examination
Fistula tracts are fibrous inflammatory tubes with a diam-
eter of 3 to 7 mm. They are lined with infected granula-
tion tissue. Many fistulas may be palpated during a careful
digital rectal examination. Essential points that should
be obtained from a clinical examination were described
nearly 100 years ago by Goodsall and Miles14; they include
the identification of the external and internal openings,
the course of the primary and any secondary tracts, and
an assessment for the presence of an underlying compli-
cating disease.
Using an anoscope, systematic inspection and palpa-
tion can define most of these characteristics. The gentle
use of a number of malleable anorectal probes and crypt
hooks can help delineate the fistula by attempting to pass
these instruments via the internal or external opening.
It is important not to force the passage of the probe
because the development of false tracts can complicate
evaluation and management. Secondary tracts may be
present when induration is palpated or asymmetry is
noted between the right and left sides of the anorectum.
In only a few cases will the use of sophisticated diagnostic
imaging techniques be required.
The external opening is identified as a small pit sur-
rounded by scar or granulation tissue. Active seropuru-
lent drainage may be present. Intersphincteric tracts
usually open externally close to the anal verge; trans-
sphincteric and other complicated tracts open farther
away. Occasionally, the external opening may be local-
ized inside the anal canal or at the distal end of a fissure.
Several external openings may be present because of
multiple complex fistula tracts; this condition is known
as “watering-pot perineum.”
The internal opening may be felt as an indurated
nodule, most often at the dentate line. This is consistent
with the cryptoglandular theory of anorectal sepsis. The
 Anal Sepsis and Fistula CHAPTER 156 1917

FIGURE 156-2 Classification of anal fistulas. A, Intersphincteric: The tract remains in the intersphincteric plane. 1, Simple. 2, High blind
tract. There is a high extension of the fistula between the internal sphincter and the longitudinal muscle of the upper anal canal. 3, High
tract with rectal opening. 4, High intersphincteric fistula without a perineal opening. There may or may not be a rectal opening. 5, High
intersphincteric fistula with a pelvic extension. The infection spreads up to reach the true pelvic cavity lying above the levator musculature.
6, Intersphincteric fistula secondary to pelvic disease. This fistula results from the spread of pelvic collections via the intersphincteric
plane. This does not represent a true anal fistula because its origin is outside the anal area. There is no opening at the dentate line.
B, Transsphincteric: The fistula tract passes from the intersphincteric plane through the external sphincter muscle. 1, Uncomplicated.
2, High blind tract. The upper tract extension may go to the apex of the ischiorectal fossa or extend higher through the levator
musculature into the pelvic cavity. C, Suprasphincteric: There is an upward extension of the fistula tract in the intersphincteric plane. The
tract then passes above the level of the puborectalis muscle and continues downward through the ischiorectal fossa to the perianal area.
D, Extrasphincteric: There is a tract that passes from the skin of the perineum through the ischiorectal fossa and the levator muscles
before entering the rectal wall. This fistula may be a consequence of an extension of a transsphincteric fistula or secondary to trauma,
anorectal disease, or pelvic inflammation.

use of saline, milk, dye, or dilute hydrogen peroxide as
an injection into the external fistula opening has been
made in an attempt to localize the internal opening. An
enlarged papilla may be noted at this site. Because most
of the anal glands are located in the posterior midline,
it is not surprising that 61% to 69% of internal openings
can be traced to this location.3
The Goodsall rule may be helpful in locating the inter-
nal opening. This rule states that an external opening
anterior to an imaginary transverse anal line in the
1918 SECTION IV Colon, Rectum, and Anus

TABLE 156-2 Incidence of Anal Fistulas

NO. OF PATIENTS TOTAL

Parks Marks and Vasilevsky and Garcia-Aguilar No. of
Fistula Type et al 9 Ritchie10 Gordon11 et al 12 Patients %
Intersphincteric 180 428 67 180 855 49.5
Transsphincteric 120 167 83 108 478 27.7
Suprasphincteric 80 24 3 6 113 6.5
Extrasphincteric 20 24 0 6 50 2.9
Miscellaneous or — 150 7 75 232 13.4
nonclassified
Total 400 793 160 375 1728 100

FIGURE 156-3 Goodsall rule.

coronal plane most likely communicates with an internal
opening lying at the end of a radial line drawn to the
nearest crypt at the dentate line. If the external opening
is posterior to this line, the internal opening will most
likely be located in the posterior midline with the tract
following a curved route to reach its source. Exceptions
to this rule include anterior openings more than 3 cm
from the anal verge and the presence of multiple exter-
nal openings. In these cases, the internal opening will
most likely be in the posterior midline (Figure 156-3).
However, the predictive accuracy of Goodsall rule has
been challenged, especially with anterior external open-
ings15 or when Crohn disease or carcinoma is present.16
SPECIAL STUDIES
Sigmoidoscopy and Colonoscopy
Sigmoidoscopy should be performed in all patients with
anorectal fistulas. The presence of associated pathology
such as neoplasms, inflammatory bowel disease, or associ-
ated secondary tracts in the rectum must be sought. Such
findings may dictate the need for full colonoscopic
evaluation.
Fistulography
Fistulography may be warranted in patients with recur-
rent fistulas or when a prior procedure has failed to
identify the internal opening. With this technique, the
external opening is cannulated with a small-caliber tube
and contrast material is injected under minimal pressure
while films are taken in several projections. Fistulography
may be useful in identifying unsuspected pathology, plan-
ning surgical management, and demonstrating anatomic
relationships. However, a study by Kuijpers and Schul-
pen17 found fistulography to be unreliable compared
with operative findings. They observed a prohibitively
high incidence of false-positive results that could lead to
unnecessary and harmful surgical exploration.

FIGURE 156-4 A, Transanal ultrasound probe (type 1850; Brüel and Kjaer, Naerum, Denmark). B, The rotating transducer is covered by a
hard plastic sonolucent cone, which is then filled with water to provide an acoustic interphase.
Intersphincteric
abscess
FIGURE 156-5 Intersphincteric abscess as seen with the use of
transanal ultrasound.
Anorectal Ultrasonography
Transanal ultrasound can delineate the muscular
anatomy of the anal sphincters in relation to an abscess
or a fistula. Most commonly, ultrasonographic examina-
tion of the anal canal is performed with the use of a
360-degree rotating probe using a 7- , 10-, or 13-MHz
transducer with a water-filled sonolucent plastic cone
over the transducer (Figure 156-4). Fistula tracts and
abscesses appear as hypoechoic defects within the mus-
cular elements of the anal canal (Figure 156-5). The
internal opening is not distinctly identified. Although
generally accurate in the localization of abscesses and
fistula tracts, primary superficial, extrasphincteric, and
suprasphincteric tracts or secondary supralevator or
infralevator tracts may be missed.18 The use of hydrogen
peroxide injected into fistulas as an image enhancer
has been shown to be safe, effective, and sometimes
helpful in the detection of these complex fistulas (Figure
156-6).19 Additionally, three-dimensional endoanal ultra-
sonography is now reliable and accurate in the diagnosis
of fistula-in-ano with or without hydrogen peroxide
enhancement.20
Anal Sepsis and Fistula CHAPTER 156 1919
The use of a linear 7-MHz ultrasound device instead
of a radial probe has been described and may carry the
advantages of greater focal depth, improved ischiorectal
and supralevator visualization, multiplanar views of
complex fistulas, and less need for echo-enhancing
injection.21 Finally, it has been shown that vaginal endo-
sonography may increase the diagnostic yield of peri-
anal sepsis in 25% of patients and may obviate the need
for uncomfortable digital or endoanal ultrasound exam-
inations in those patients with hidden abscesses or anal
stenosis.22
Magnetic Resonance Imaging
Another accurate method of imaging anal fistula disease
is magnetic resonance imaging (MRI). A majority of
anal fistulas have a single simple fistula track that is
easily identified during surgery. However, 5% to 15% of
complex fistulas are often associated with recurrent fis-
tulas and fistulas associated with underlying Crohn
disease. MRI has shown to be helpful, especially in these
complex fistulas in identification of fistulous tracks, sec-
ondary extensions, and internal openings.23 In a study
by Beets-Tan et al, preoperative MRI had a sensitivity
and specificity of 100% and 86%, respectively, in iden-
tification of fistula tracks. Additionally, the study found
a 96% sensitivity and 90% specificity for preoperative
MR detection of internal fistula openings.23 MRI is
particularly useful in the evaluation of complex fistu-
lous disease. Combining MRI with endoanal ultrasonog-
raphy and an examination under anesthesia may
enhance the accuracy of these tests in determining
fistula anatomy.24
Computed Tomography
The use of computed tomography (CT) in the evaluation
of anal fistulas is limited because of poor visualization of
the levators and sphincter complex. The role of CT in
anal sepsis and fistula is thus limited to the assessment
of associated pelvic pathology in patients with suprale­
vator abscesses and in patients with some complex anal
fistulas.
1920 SECTION IV Colon, Rectum, and Anus

Enhanced fistula tract

Nonenhanced fistula tract

A

Left ischiorectal
abscess
Fistula tract

Deep postanal
abscess
B1

Left ischiorectal
abscess

Fistula tract
Right side
extension

Deep postanal
abscess
B2
FIGURE 156-6 A, Transsphincteric hypoechogenic tract extending toward the posterior midline. The tract is enhanced as hydrogen
peroxide is injected into the external opening. B, Complex fistula tract and collections as seen without (1) and with (2) hydrogen peroxide
enhancement. Hydrogen peroxide enhancement allowed for a more precise delineation of the tracts in addition to a right-sided extension
of the tract.

Anorectal Manometry The selective use of anorectal manometry is especially

Anorectal manometry is an objective method for study-
ing the contribution of the anorectal sphincter to the
physiologic process of defecation. Manometry can assist
in identifying patients at the greatest risk for postopera-
tive incontinence. Surgical management can be tailored
accordingly, improving clinical and functional outcome.
warranted in patients with suspected sphincter impair-
ment; patients suspected of needing substantial portions
of the external sphincter divided for fistula cure; and
women with a history of multiparity, forceps delivery,
third-degree perineal tear, high birthweight, or pro-
longed second stage of labor.16 Patients with lower

A B
FIGURE 156-7 A, Cruciate incision made over the most tender or fluctuant area. B, The skin edges are excised.
preoperative resting pressures have significantly poorer
continence control following surgery for intersphincteric
fistula when compared prospectively to patients with
normal preoperative resting pressures.25
Fistuloscopy
Anorectal fistuloscopy using flexible ureteroscopes has
been described.26 This is a potentially useful intraopera-
tive technique used to identify primary fistula openings,
multiple or complex tracts, and iatrogenic tracts. Modi-
fied flexible ureteroscopes are in the early developmen-
tal stages. We look forward to their evolution because
they represent a novel diagnostic and therapeutic tool
that may significantly improve the outcomes of complex
fistula diagnosis and treatment.
TREATMENT
ANORECTAL ABSCESS
The treatment of anorectal abscesses should be consid-
ered a surgical emergency, with early drainage the main-
stay of treatment. There is no place for conservative
management. Treatment delay may result in chronic
infection and tissue destruction with fibrosis and long-
term impairment of function. The condition of the
patient and the type of abscess usually determine whether
drainage can be performed in the office or emergency
department or in the operating room. Antibiotics should
be used as adjunctive therapy in special circumstances
only; these include patients with valvular heart disease,
immunosuppression, extensive associated cellulitis, and
diabetes.
Anorectal abscesses associated with gut-derived organ-
isms are more likely to be associated with an underlying
fistula than are abscesses associated with skin-derived
organisms.27 However, the positive predictive value for
this association has been found to be quite low; there-
fore, cultures are rarely indicated.28
Perianal Abscess
Simple perianal abscesses can almost always be drained
as an office or outpatient procedure, usually under local
anesthesia. A cruciate incision is made over the most
Anal Sepsis and Fistula CHAPTER 156 1921
tender or fluctuant point as close to the anal verge
as possible. If a fistula develops, the external opening
will be close to the verge, so a fistulotomy would require
division of the least amount of muscle. The skin edges
are usually excised to avoid early coaptation, which
could seal the cavity prematurely and lead to recurrence
(Figure 156-7).
After all loculations are broken, packing is not
required; packing contributes to significant discomfort
and does not allow for free drainage of the abscess cavity.
Continued drainage of large cavities may be achieved
with the use of a 3- to 5-mm de Pezzer or similar catheter
left in situ until drainage subsides. This technique may
be used in a number of different abscesses but is not
suitable for use in cases of submucous or intersphincteric
abscess.
Ischiorectal Abscess
After horseshoe extension is excluded by ensuring that
the deep postanal space is not involved, unilateral ischio-
rectal abscesses may be drained through a single incision
or several counterincisions over the area of maximal
swelling, pain, and fluctuance but as close to the anal
verge as possible. Here, too, a de Pezzer catheter may be
used to enhance the drainage of large cavities.
Intersphincteric Abscess
An intersphincteric abscess is drained by laying open the
internal sphincter (sphincterotomy) overlying the cavity.
By definition, a fistulotomy is performed by destruction
of the inciting anal gland. For hemostasis, adequate
drainage, and faster healing, the edges of the wound may
be marsupialized.
Submucosal Abscess
Submucosal abscesses are drained internally by incising
the mucosa over the abscess. The edges of the wound
may be marsupialized. No packing or drainage catheter
is indicated.
Supralevator Abscess
Anatomic localization of the septic origin is of para-
mount importance in the management of supralevator
collections. Collections that result from abdominopelvic
1922 SECTION IV Colon, Rectum, and Anus
FIGURE 156-8 Appropriate type of drainage of supralevator
abscesses depending on the course taken by the fistula tract.
disease may be drained transrectally or transabdominally.
Overall management depends on the underlying pathol-
ogy. Supralevator collections that result from an upward
extension of an intersphincteric abscess should be
drained transrectally. Transperineal drainage through
the ischiorectal fossae could result in a suprasphincteric
fistula. Supralevator collections that result from the
cephalad extension of a transsphincteric fistula or an
ischiorectal collection should be drained transperineally
through the ischioanal fossae. If erroneously drained
transrectally, the result will be an extrasphincteric fistula.
Transperineal drainage of this type of collection will
likely result in a transsphincteric fistula that is relatively
easy to manage (Figure 156-8).
Postanal Abscess and Horseshoe Extension
Hanley first described the conservative surgical approach
to a horseshoe abscess that preserved function and
anatomy.29 The abscess in the postanal space is drained
by a deep posterior midline incision. All of the muscles
attached to the coccyx, the superficial external sphincter,
and the lower edge of the internal sphincter are divided.
When the suppurative process extends to the ischiorectal
spaces as a horseshoe, one or multiple secondary inci-
sions are placed in the skin overlying the ischiorectal
space. These may be connected to each other with soft
drains to allow for continuous drainage. We favor a modi-
fication of Hanley’s technique in which the posterior
midline incision consists of only a partial distal internal
sphincterotomy to include a fistulotomy with destruction
of the anal gland at the dentate line. The external sphinc-
ter and the muscular attachments to the coccyx are not
divided. This allows for faster healing while maintaining
FIGURE 156-9 Drainage of a postanal abscess with horseshoe
extension. The postanal space has been laid open as described
by Hanley. Secondary incisions are placed in the skin overlying
the ischiorectal space.
adequate drainage (Figure 156-9). Counterincisions and
drains are used for horseshoe extensions as previously
described.
Primary Versus Delayed Fistulotomy
The use of primary fistulotomy when draining an abscess
remains controversial. Issues surrounding this contro-
versy include the ability to localize an internal opening
at the time of an acute septic event and the effect of
primary fistulotomy on recurrence and continence. Does
the type of abscess affect the risk of recurrent fistula? Is
it cost-effective to take a patient for whom an outpatient
procedure is performed under local anesthesia to the
operating room for a thorough examination under
general anesthesia and a primary fistulotomy in the hope
of avoiding a second procedure for a fistula that might
develop if only simple drainage were performed?
A one-stage procedure theoretically destroys the cryp-
toglandular source of sepsis, decreasing the incidence of
fistula formation. However, internal openings may not
always be found. Attempts to define a primary opening
in the setting of an acute infection may be a hazardous
undertaking. Not all abscesses lead to fistulas; hence,
some patients would undergo an unnecessary procedure
that puts them at risk for incontinence.
The reported incidence of recurrent abscess and sub-
sequent development of anorectal fistula varies consider-
ably. Scoma et al7 found that 66% of 232 patients
developed a fistula or recurrent abscess after incision and
drainage alone. Vasilevsky and Gordon8 found that 11%
of 83 patients developed recurrent abscess and 37%
developed a fistula after incision and drainage. They
noted that the greatest risk of recurrence was in patients
who had ischiorectal abscesses, an observation we have
also made. The subset of patients with no previous
episode of anorectal suppuration had a lower incidence
of recurrence. Both authors advocated incision and

drainage alone for acute abscesses, reserving fistulotomy
as a secondary procedure in patients with recurrence.
In contrast, several authors favor a policy of immedi-
ate fistulotomy in the treatment of anorectal abscesses.
In a series of almost 800 cases, Eisenhammer30 described
a nearly 100% cure rate obtained with a single operation.
McElwain et al4 reported on the outcome of 1000 cases
of primary fistulotomy for anorectal abscesses, including
intersphincteric and postanal abscesses. The recurrence
rate was 3.6%, and the disturbance of continence rate
was 3.2%. This approach is further supported by a ran-
domized, prospective trial of 200 patients. Oliver et al
demonstrated that drainage with fistulotomy was safe
(incontinence 6% at 1 year) and effective (recurrence
5% at 1 year) when compared with drainage alone (0%
incontinence and 29% recurrence).31 Ultimately, this
approach requires the consistent finding of an internal
opening to perform fistulotomy. In general, internal
openings can be identified in 34% to 88% of acute
abscesses.5,32
In summary, a percentage of patients who have drain-
age alone for the treatment of anal abscess develop a
recurrent abscess or subsequent fistula. A primary fistu-
lotomy in this setting may decrease this risk but at the
expense of a small increase in the risk for disturbances
of continence. Primary fistulotomy should be considered
in patients who have a history of previous anorectal sepsis
or who present with an ischiorectal abscess with an inter-
nal opening that is readily apparent. This controversy has
no impact in dealing with postanal abscesses with horse-
shoe extensions or intersphincteric abscesses. In these
cases, a fistulotomy is performed when the sphincterot-
omy is the primary drainage technique.
ANORECTAL FISTULAS
Once diagnosed, patients with anorectal fistulas should
undergo surgical treatment. Anorectal fistulas rarely heal
spontaneously. Untreated patients frequently develop
chronic abscess formation and complex fistula tracts.
Surgical treatment for most anorectal fistulas is best
accomplished in the operating room, with good lighting
and appropriate instrumentation. The patient is posi-
tioned in prone jackknife position with the buttocks
taped apart. General, regional, or local anesthesia with
intravenous sedation should be selected on the basis of
individual patient characteristics. The three basic surgi-
cal techniques for the treatment of anorectal fistulas are
fistulotomy, use of a seton, and endorectal advancement
flaps. The use of fistulectomy is not recommended except
when it is necessary to provide histologic material.
Fistulotomy
Most anorectal fistulas may be adequately treated by the
classic laying-open technique or fistulotomy. Recurrence
rates are low, and risks for continence disturbances are
minimal.3 A fistulotomy is accomplished by passing a
fistula probe via the external opening, along the tract,
and through the internal opening. With the probe in
place, the relationship of the fistulous tract to the exter-
nal sphincter muscle can be determined. If the tract lies
distal to the majority of the external muscle, then cautery
is used to lay it open. Secondary tracts should be drained
Anal Sepsis and Fistula CHAPTER 156 1923
through the fistulotomy incision after all tracts have been
curetted. Marsupialization with a running continuous
absorbable suture is associated with faster healing.
In patients with otherwise normal continence, the
perianal skin, anal epithelium, a portion of the internal
anal sphincter, and a few fibers of subcutaneous external
sphincter may be divided with minimal risk of inconti-
nence. However, in women with anterior fistulas, such a
fistulotomy is associated with an unacceptably high risk
of incontinence because of the intrinsic thin nature of
the sphincter mechanism in this area. Therefore,
sphincter-preserving techniques should be used in the
treatment of anterior fistulas in women.
Recently, a method termed the LIFT procedure or
“ligation of the intersphincteric fistula tract” has become
popular. This is a novel sphincter-preserving method for
fistula closure that involves making an incision in the
intersphincteric groove, dissection between the sphinc-
ter muscles, and identification of the fistula tract. The
fistula probe is left in situ during this time to facilitate
identification of the tract. The fistula tract is then dis-
sected free and the probe removed. Next, the fistula tract
is divided and ligated. The internal opening is closed
with absorbable suture and the external opening curet-
ted and left open to drain. Initial retrospective studies
show this procedure has a success rate similar to other
sphincter-preserving procedures, between 57% and
82%.33,34
Seton Management
The word seton is derived from the Latin word seta,
meaning “bristle.” It refers to any foreign material that
can be inserted into the fistula tract to encircle the
sphincter muscles. These materials may include silk,
Penrose drains, Silastic vessel loops, rubber bands, nylon
or polypropylene, and braided steel wire. Setons are
placed by securing the selected material to the end of a
fistula probe after the probe has been passed through
the internal opening (Figure 156-10).
Setons are useful in the management of complex ano-
rectal fistulas where there is an appreciable risk of incon-
tinence or poor healing; such cases include patients with
Crohn disease, immunocompromised and incontinent
patients, patients with chronic diarrheal states, and ante-
rior fistulas in women. Complete healing of selected ano-
rectal fistulas has been reported solely with the use of
long-term setons.35
Setons may be used for marking, draining, cutting, or
staging. A marking seton is useful when it is difficult to
determine the amount of muscle the fistula tract crosses.
Encircling the tract with a seton allows the surgeon to
assess the amount of muscle, particularly the puborecta-
lis, once the patient is awake. If adequate muscle is
present above the fistula tract, a fistulotomy may be per-
formed without significant risk for incontinence.
A draining seton traverses a fistula tract to provide
long-term drainage of a septic process. It may be used as
a bridge to definitive surgical therapy or be left in place
for long periods. Epithelialization of the tract prevents
recurring abscesses. Long-term draining setons are tied
loosely. They are particularly useful in the management
of complex fistulas associated with Crohn disease. The
1924 SECTION IV Colon, Rectum, and Anus
FIGURE 156-10 Insertion of a seton with the aid of a fistula probe.
combination of a draining seton and immunomodula-
tion therapy with infliximab appears to improve out-
comes while maintaining sphincter function in Crohn
patients with complex anal fistulas.36
A cutting seton is used to gradually transect the stri-
ated sphincter muscle. This technique promotes fibrosis
in the tissue surrounding the muscle encircled by the
seton. At regular, 2-week intervals, the seton is progres-
sively tightened, dividing the muscle by a process of isch-
emic necrosis. The cut edge of the divided muscle does
not separate because of the fibrosis that forms during the
time it takes to divide the muscle. The seton can be pro-
gressively tightened with silk ligatures. Alternatively, a
hemorrhoid ligator may be used to progressively tighten
the seton with rubber bands.
When a staging seton is used, the fistula tract is identi-
fied and only the most superficial portion is divided. The
seton is placed through that portion of the fistula tract
that traverses the sphincter, thus encircling the muscle.
This portion of the tract is divided as a second procedure
once adequate fibrosis occurs (usually 8 weeks). A “high”
fistula may be converted to a “low” fistula by dividing only
the proximal portion of the tract, leaving the distal tract
encircled with a seton for division at a later date.
Whether to use a cutting seton or a staging seton with
second-stage fistulotomy appears to be up to surgeon
preference. In a study of 59 patients with high anal
fistula, Garcia-Aguilar et al37 showed no difference in
fistula eradication, incontinence, and patient satisfaction
between 12 patients treated with cutting setons and 47
treated with two-stage seton fistulotomy.
Anorectal Advancement Flaps
Advancement flaps consist of mucosa, submucosa, and
part of the internal sphincter. The underlying fistula tract
is debrided, and the internal opening is sutured at the
level of the muscle. The edge of the elevated flap con-
taining the internal opening is excised, and the flap is
advanced and sutured over the internal defect (Figure
156-11).
Advancement flaps offer the advantage of a one-stage
procedure, quicker healing, limited damage to the
underlying sphincter, and minimal risk of anal canal
deformity.3 Several studies have reported good success,
with few complications using anorectal advancement
flaps in the treatment of both simple and complex
fistulas.38
Fibrin Glue
The use of fibrin glue in the management of anorectal
fistulas has been popularized. A prepared mixture of
fibrinogen and thrombin is injected into the fistula tract
after it has been curetted. The resulting coagulum plugs
the fistula tract. This technique represents an alternative
mode of treatment in complex cases for which standard
treatment has failed. The complete healing rate in one
series was 60% and included patients with Crohn disease
and human immunodeficiency virus (HIV)–associated
anal disease.39 Sentovich performed a two-stage fistulot-
omy with injection of fibrin glue into the external
opening after seton removal at the second operation,
with 69% success in 48 patients.40 Buchanan et al41 found
only a 14% complex fistula closure rate in 22 patients.
Despite mixed results, fibrin glue remains a viable treat-
ment option because of its safety, ease of application, and
low risk of sphincter injury.
Fistula Plug
Recently, a cone-shaped fistula plug created from a bio-
absorbable xenograft made of lyophilized porcine intes-
tinal submucosa has become available for high
transsphincteric fistulas. The material has an inherent
resistance to infection, produces no foreign body or
giant cell reaction, and becomes repopulated with host
cell tissue during a period of 3 months. The fistula plug
is inserted into the primary opening of the fistula and
secured into place with one or two interrupted stitches.
This intervention appears to be a safe option as it pre-
serves anal function and is associated with a low morbid-
ity. In prospective studies of complex fistula-in-ano, there
was a moderate success rate of 35% to 87%.42 Further
randomized controlled trials studying objective parame-
ters of fistula healing are needed to substantiate these
findings.
POSTOPERATIVE CARE
In general, most anorectal surgery is performed as an
outpatient procedure. Patients are instructed to consume

A B
C
FIGURE 156-11 A, Anorectal advancement flap for closure of the internal opening in the treatment of perianal fistulas. The base of the flap
should be wider than the apex. B, With the flap elevated, the internal opening is debrided and closed with a suture. C, The apex of the
flap is advanced and sutured over the defect.
a high-fiber diet postoperatively. No bowel confine-
ment regimen is required for the treatment of simple
conditions. For complex procedures, bowel confinement
has been recommended, but it is of questionable value.43
Sitz baths are recommended for perianal hygiene and
comfort. More complex procedures may require inpa-
tient status for pain management and wound care.
Wound healing after fistulotomy usually takes 4 to 8
weeks. Patients with an anorectal abscess should be
followed closely after drainage for possible fistula
development.
COMPLICATIONS
Complications after surgical intervention for anorectal
suppurative disease are numerous and related to surgical
technique. Urinary retention is the most common com-
plication, occurring in up to 25% of patients.44 Other
complications include hemorrhage, acute external
thrombosed hemorrhoids, cellulitis, fecal impaction,
stricture, rectovaginal fistula, incontinence, and recur-
rence. Local wound problems and complications associ-
ated with anesthesia, such as hypotension, hypertension,
and seizures, have also been reported. The issue of fistula
recurrence after drainage of anorectal abscess has been
discussed previously.
The rate of recurrent fistula after fistulotomy ranges
from 0% to 18%,45 although the true incidence is prob-
ably around 3% to 7%.5,12 The primary causes of fistula
Anal Sepsis and Fistula CHAPTER 156 1925
recurrence relate to unrecognized internal openings and
inadequate drainage of abscess cavities.2 In a study of 375
patients, Garcia-Aguilar12 found that recurrence was also
associated with lateral location of internal openings and
fistulas with horseshoe extension.
The rate of disorders of continence after fistulotomy
ranges from 18% to 52%.45 Factors associated with incon-
tinence risk include the complexity of the fistula, female
sex, division of a significant portion of the external
sphincter, the use of two-stage seton or cutting seton
fistulotomy (probably because of complexity of the
fistula), and a history of prior fistula surgery.12
SPECIAL CONSIDERATIONS
CROHN DISEASE
Crohn disease manifests with perianal or rectal symptoms
in approximately one-third of patients and is associated
with a more aggressive natural history (see Chapters 159
and 161), with many due to anorectal sepsis and fistula.46
Anorectal abscess in patients with Crohn disease should
be treated with prompt drainage. Long-term catheter
drainage has been found to be safe and effective and may
be of benefit in preventing or delaying recurrence and
the subsequent need for proctectomy.
The treatment of anorectal fistulas in patients with
Crohn disease should be tailored to the specific situation
encountered. Consideration should be given to the
1926 SECTION IV Colon, Rectum, and Anus
complexity of the fistula and the presence of active
Crohn disease in the rectum. In general, treatment
modalities should be conservative. Extensive procedures
may increase the risk of incontinence and nonhealing
wounds. A simple fistula in a patient with a normal
rectum can be treated by primary fistulotomy with good
outcome and satisfactory healing rates.47 Complex fistu-
las in patients with active rectal Crohn disease remain a
therapeutic challenge. These cases are better served with
prolonged drainage to achieve long-term palliation. In
selected cases, rectal advancement flaps may be used with
good functional results.48 Some patients with complex
anorectal fistulas in the presence of anal Crohn may
require diversion of the fecal stream for symptomatic
relief. Ultimately, between 12% and 39% of patients will
require proctectomy for progressive intestinal disease or
intractable perianal disease.49 Shinozaki et al, in a series
of 39 patients, found that simultaneously performing a
bowel resection for active Crohn disease at the time of
drainage of perianal sepsis or draining seton placement
led to better healing of the anal fistula.50 It is theorized
that control of the intraabdominal Crohn disease
improves healing of perianal Crohn fistulas.
A monoclonal antibody to tumor necrosis factor (TNF-
α) was approved in August 1998 by the U.S. Food and
Drug Administration for the treatment of patients with
fistulizing Crohn disease. Infliximab (Remicade) is a
genetically constructed murine-human chimeric immu-
noglobulin. It neutralizes the biologic activity of TNF-α
and inhibits binding to its receptors. A randomized trial
in which infliximab was used in the management of
patients with Crohn fistulas (perianal and abdominal)
demonstrated a 62% clinical response (defined as >50%
reduction from baseline in the number of draining fistu-
las) and a 46% complete closure of all fistulas compared
with 26% and 13%, respectively, of patients in the placebo
group.51 However, the duration of response is short-lived.
Repeat treatment or chronic use may be required for a
long-term beneficial effect.
FISTULA IN INFANCY
Anal fistula in infancy occurs almost exclusively in
otherwise healthy boys younger than 2 years of age. The
cause of this condition appears to be a congenital abnor-
mality of the anal glands with abnormally deep and thick
crypts of Morgagni. These factors predispose the patients
to cryptitis with abscess and fistula formation. Simple
fistulotomy is recommended in this patient population
with expected good results. A concomitant cryptotomy
has been recommended by some to decrease the like­
lihood of recurrence. Nonoperative management is
favored by those who believe that abscess and fistula are
self-limited in this population. Opponents argue that
such fistula disease is seldom time limited. They argue
that the process is truly characterized by frequent inter-
mittent relapse or a prolonged silent state with late recur-
rence requiring subsequent intervention.
MALIGNANT TRANSFORMATION IN CHRONIC
ANAL FISTULA
Carcinoma arising in an anorectal fistula is a rare condi-
tion. Rosser52 established the first association between
adenocarcinoma and anal fistula. There is controversy
regarding the possibility of malignancy arising from a
benign anorectal fistula. A slow-growing cancer may not
become evident for years, and in some cases the fistula
could result from the breakdown of a neoplasm. To rule
out the preexistence of even the slowest growing cancer,
it has been arbitrarily determined that a fistula should
have been present for at least 10 years before the diag-
nosis of carcinoma if malignant transformation is to be
considered.
Carcinoma arising in anorectal fistulas in patients with
Crohn disease has been reported; the estimated inci-
dence is 0.7%.53 Deep biopsy samples, careful histologic
examination of atypical cells obtained from ductal struc-
tures, and a high index of suspicion in cases of long-
standing anorectal fistulas may provide a clue to the
diagnosis of underlying carcinoma. Resection with either
wide local excision or abdominoperineal resection has
the potential to result in cure.
ANORECTAL SEPSIS AND FISTULA IN HUMAN
IMMUNODEFICIENCY VIRUS DISEASE
Anorectal disease is a prevalent problem in the HIV-
positive population, with an estimated frequency of 6%
to 34%.54 Although there is concern in performing elec-
tive anorectal surgery in this population because of the
fear of poor healing, symptomatic anorectal sepsis and
fistula often require surgical management. Treatment
should be tailored to the patient’s severity of illness.
The risk for disturbed wound healing increases as the
preoperative CD4+ count decreases. The presence of an
acquired immunodeficiency syndrome and a white
blood cell count of less than 3000/mm3 are also associ-
ated with poor wound healing.55 In the absence of these
risk factors, fistulotomy for simple fistulas may be per-
formed with expected good results. For complex fistulas
and patients with risk factors for poor healing, the
liberal use of draining setons is recommended for symp-
tomatic relief.
ANORECTAL COMPLICATIONS IN PATIENTS
WITH LEUKEMIA
Anorectal complications in patients with leukemia repre-
sent a rare but potentially life-threatening problem. The
incidence of concomitant symptomatic anorectal disease
and leukemia has been reported to be as high as 5.8%,
with acute anorectal sepsis accounting for a majority of
all cases.56 The mortality rate for patients with acute peri-
anal sepsis in this population has been reported to be
from approximately 20%.57 In general, surgical treat-
ment of anorectal sepsis in uncontrolled acute leukemia
has been avoided because of the fear that the septic
process would spread and wound healing would be
impaired. Historically, this led to a policy of combined
radiation therapy and symptomatic care as primary treat-
ment, with surgical management reserved for the drain-
age of an obviously fluctuant abscess. Symptomatic care
consisted of sitz baths or warm compresses, stool soften-
ers, analgesic agents, and broad-spectrum antibiotics.
Additional precautionary measures included no rectal
examinations, no instrumentation, and no enemas.
However, reports indicate that surgical intervention in

the form of incision and drainage appears to be safe in
this patient population.56
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