Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula
Publication Date: July 4, 2022
Last Updated: July 25, 2022
Initial Evaluation of Anorectal Abscess and Fistula
A disease-specific history and physical examination should be performed evaluating symptoms, relevant history, abscess and fistula location, and presence of secondary cellulitis. (1C)
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Routine use of diagnostic imaging is not typically necessary for patients with anorectal abscess or fistula. However, imaging may be considered in selected patients with an occult anorectal abscess, recurrent or complex anal fistula, immunosuppression, or anorectal 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 in selected patients with simple anal fistulas. (2B)
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Antibiotics should typically be reserved for patients with an anorectal abscess complicated by cellulitis, systemic signs of infection, or underlying immunosuppression. (2B)
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Anal Fistula
Patients with a simple fistula-in-ano and normal anal sphincter function may be treated with lay-open fistulotomy. (1B)
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Fistula-in-ano may be treated with endorectal advancement flap. (1B)
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Transsphincteric fistulas may be treated with ligation of the intersphincteric fistula tract (LIFT) procedure. (1B)
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A cutting seton may be used selectively in the management of complex cryptoglandular anal fistulas. (2C)
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The anal fistula plug and fibrin glue are relatively ineffective treatments for fistula-in-ano. (1B)
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Minimally invasive approaches to treat fistula-in-ano that use endoscopic or laser closure techniques have reasonable short-term healing rates but unknown long-term fistula healing and recurrence rates. (2C)
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Rectovaginal Fistula
Nonoperative management is typically recommended for the initial care 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 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 patients with a rectovaginal fistula. (1C)
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Episioproctotomy may be used to repair obstetrical or cryptoglandular rectovaginal fistulas in patients with anal sphincter defects. (1C)
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A gracilis muscle or bulbocavernosus (Martius) flap is typically recommended for recurrent or otherwise complex rectovaginal fistula. (1C)
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Rectovaginal fistulas that result from colorectal anastomotic complications often require a transabdominal approach for repair. (1C)
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Completion proctectomy with or without colonic pull-through or coloanal anastomosis may be required to treat radiation-related or recurrent complex rectovaginal fistula. (2C)
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Anorectal Fistula Associated With Crohn’s Disease
Anorectal fistula associated with Crohn’s disease is typically managed with a combination of surgical and medical approaches. (1B)
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Asymptomatic fistulas in patients with Crohn’s disease typically do not require surgical treatment. (1C)
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Draining setons are typically useful in the multimodality therapy of fistulizing anorectal Crohn’s disease and may be used for long-term disease control. (1B)
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Symptomatic, simple, low anal fistulas in carefully selected patients with Crohn’s disease may be treated by lay-open fistulotomy. (2C)
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Endorectal advancement flaps and the LIFT procedure may be used to treat fistula-in-ano associated with Crohn’s disease. (1B)
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Patients with uncontrolled symptoms from complex anorectal fistulizing Crohn’s disease may require fecal diversion or proctectomy. (1C)
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Local administration of mesenchymal stem cells is a safe and effective treatment for selected patients with refractory anorectal fistulas in the setting of Crohn’s disease. (2B)
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Tables
Table 1. Parks classification of fistula-in-ano
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| 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. |
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
July 4, 2022
Last Updated Month/Year
April 1, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management
Diseases/Conditions (MeSH)
D012006 - Rectovaginal Fistula, D000071056 - Anorectal Malformations
Keywords
Anorectal Abscess, Fistula-in-Ano, Rectovaginal Fistula
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.
Methodology
Number of Source Documents
267
Literature Search Start Date
November 30, 2015
Literature Search End Date
November 4, 2021