Perianal Sepsis and Fistula

  • Parvez Sheikh
  • Prasang Bajaj


Anal fistula and anal sepsis are the part of spectrum of anorectal suppurative diseases. The abscess represents the acute inflammatory event, whereas the fistula is representative of the chronic process. A perianal abscess (also known as anorectal abscess or anal sepsis) is an infection of the soft tissues surrounding the anal canal with formation of a discrete abscess cavity. A fistula-in-ano is a hollow tract lined with granulation tissue connecting a primary opening inside the anal canal to a secondary opening in the perianal skin through which an abscess has been drained or has spontaneously ruptured. In some fistulas, there may be only an internal opening leading to a blind tract. Symptoms generally affect quality of life significantly and range from minor discomfort and drainage with resultant hygienic problems to distressing sepsis. Treating an abscess is relatively straightforward. However, eradicating anorectal fistulas is challenging and often frustrating for both the surgeon and the patient. The lack of any standard surgical procedure and heterogeneity of anorectal fistula warrants the surgeon to use his “judgment” more than in most colorectal diseases.


Anal Fistula Internal Opening Internal Sphincter Advancement Flap Fistulous Tract 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Arroyo A, Pérez-Legaz J, Moya P, et al. Fistulotomy and sphincter reconstruction in the treatment of complex fistula-in-ano: long-term clinical and manometric results. Ann Surg. 2012;255(5):935–9.CrossRefPubMedGoogle Scholar
  2. Beets Tan RG, Beets GL, van Der Hoop AG, et al. Preoperative MR imaging of anal fistulas: does it really help the surgeon? Radiology. 2001;218:75.CrossRefPubMedGoogle Scholar
  3. Benjelloun EB, Jarrar A, El Rhazi K, et al. Acute abscess with fistula: long-term results justify drainage and fistulotomy. Updates Surg. 2013;65(3):207–11.CrossRefPubMedGoogle Scholar
  4. Brook I, Frazier EH. The aerobic and anaerobic bacteriology of perirectal abscess. J Clin Microbiol. 1997;35:2974–6.PubMedCentralPubMedGoogle Scholar
  5. Cariati A. Fistulotomy or seton in anal fistula: a decisional algorithm. Updates Surg. 2013;65(3):201–5.CrossRefPubMedGoogle Scholar
  6. Champagne BJ, O’Connor LM, Ferguson M, et al. Efficacy of anal fistula plug in closure of cryptoglandular fistulas: long-term follow-up. Dis Colon Rectum. 2006;49(12):1817–21.CrossRefPubMedGoogle Scholar
  7. Choen S, Burnett S, Bartram CI, et al. Comparison between anal endosonography and digital examination in the evaluation of anal fistulae. Br J Surg. 1991;78:445–7.CrossRefPubMedGoogle Scholar
  8. Cirocco WC, Reilly JC. Challenging the predictive accuracy of Goodsall’s rule for anal fistula. Dis Colon Rectum. 1992;35:537.CrossRefPubMedGoogle Scholar
  9. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. Circulation. 1997;96:358–66.CrossRefPubMedGoogle Scholar
  10. Ellis CN. Outcomes with the use of bioprosthetic grafts to reinforce the ligation of the intersphincteric fistula tract (BioLIFT procedure) for the management of complex anal fistulas. Dis Colon Rectum. 2010;53(10):1361–4.CrossRefPubMedGoogle Scholar
  11. Ellis CN, Rostas JW, Greiner FG. Long-term outcomes with the use of bioprosthetic plugs for the management of complex anal fistulas. Dis Colon Rectum. 2010;53(5):798–802.CrossRefPubMedGoogle Scholar
  12. Faucheron J, Saint-Marc O, Guibert L, Parc R. Long-term seton drainage for high anal fistulas in Crohnʼs disease-A sphincter-saving operation?. Diseases of the Colon & Rectum. 1996;39(2):208–211.CrossRefGoogle Scholar
  13. Fazio VW. Complex anal fistulae. Gastroenterol Clin North Am. 1987;16:93.PubMedGoogle Scholar
  14. Frudinger A, Halligan S, Bartram CI, et al. Female anal sphincter: age-related differences in asymptomaticm volunteers with high frequency endoanal US. Radiology. 2002;224:417–23.CrossRefPubMedGoogle Scholar
  15. Garcia-Olmo D, Herreros D, Pascual I, et al. Expanded adipose-derived stem cells for the treatment of complex perianal fistula: a phase II clinical trial. Dis Colon Rectum. 2009;52(1):79–86.CrossRefPubMedGoogle Scholar
  16. Gordon PH, Nivatvongs S. Principles and practice of surgery for the colon, rectum and anus. Quality Medical Publishing; New York. 1999. p. 241–283Google Scholar
  17. Grace RH, Harper IA, Thompson RG. Anorectal sepsis: microbiology in relation to fistula-in-ano. Br J Surg. 1982;69:401–3.CrossRefPubMedGoogle Scholar
  18. Halligan S, Stoker J. Imaging of fistula in ano 1. Radiology. 2006;239:18–33.CrossRefPubMedGoogle Scholar
  19. Hamadani AB, Haigh PI, Liu IA, et al. Who is at risk for developing chronic anal fistula or recurrent anal sepsis after initial perianal abscess? Dis Colon Rectum. 2009;52:217–21.CrossRefPubMedGoogle Scholar
  20. Hammond TM, Grahn MF, Lunniss PJ. Fibrin glue in the management of anal fistulae. Colorectal Dis. 2004;6(5):308–19.CrossRefPubMedGoogle Scholar
  21. Henrichsen S, Christiansen J. Incidence of fistula-in-ano complicating anorectal sepsis: a prospective study. Br J Surg. 1986;73:371–2.CrossRefPubMedGoogle Scholar
  22. Herreros MD, Garcia-Arranz M, Guadalajara H, et al. Autologous expanded adipose-derived stem cells for the treatment of complex cryptoglandular perianal fistulas: a phase III randomized clinical trial (FATT 1: fistula Advanced Therapy Trial 1) and long-term evaluation. Dis Colon Rectum. 2012;55(7):762–72.CrossRefPubMedGoogle Scholar
  23. Isbister WH. A simple method for the management of anorectal abscess. Aust N Z J Surg. 1987;57:771–4.CrossRefPubMedGoogle Scholar
  24. Jacob TJ, Perakath B, Keighley MR. Surgical intervention for anorectalfistula. Cochrane Database Syst Rev. 2010; (5):CD006319.Google Scholar
  25. Jarrar A, Church J. Advancement flap repair: a good option for complex anorectal fistulas. Dis Colon Rectum. 2011;54(12):1537–41.CrossRefPubMedGoogle Scholar
  26. Johnson E, Gaw JU, Armstrong DN. Role of anorectal fistuloscopy in evaluating complex anorectal fistulas. Dis Colon Rectum. 2005;48:631.Google Scholar
  27. Jones J, Tremaine W. Evaluation of perianal fistulas in patients with crohn’s disease. MedGenMed. 2005;7(2):16.PubMedCentralPubMedGoogle Scholar
  28. Kuijpers HC, Schulpen T. Fistulography for fistula-in-ano: is it useful? Dis Colon Rectum. 1985;28:103–4.CrossRefPubMedGoogle Scholar
  29. Law PJ, Bartram CI. Anal endosonography: technique and normal anatomy. Gastrointest Radiol. 1989;14(1):349–535.CrossRefPubMedGoogle Scholar
  30. Leng Q, Jin HY. Anal fistula plug vs mucosa advancement flap in complex fistula-in-ano: a meta-analysis. World J Gastrointest Surg. 2012;27(4(11)):256–61.CrossRefGoogle Scholar
  31. Lim CH, Shin HK, Kang WH, et al. The use of a staged drainage seton for the treatment of anal fistulae or fistulous abscesses. J Korean Soc Coloproctol. 2012;28(6):309–14.PubMedCentralCrossRefPubMedGoogle Scholar
  32. Llera JL, Levy RC. Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med. 1985;14:15–9.CrossRefPubMedGoogle Scholar
  33. Loungnarath R, Dietz DW, Mutch MG, et al. Fibrin glue treatment of complex anal fistulas has low success rate. Dis Colon Rectum. 2004;47(4):432–6.CrossRefPubMedGoogle Scholar
  34. Lunniss PJ, Armstrong P, Barker PG, et al. Magnetic resonance imaging of anal fistulae. Lancet. 1992;340:394–6.CrossRefPubMedGoogle Scholar
  35. Macfie J, Harvey J. The treatment of acute superficial abscesses: a prospective clinical trial. Br J Surg. 1977;64:264–6.CrossRefPubMedGoogle Scholar
  36. Malik AI, Nelson RL, Tou S. Incision and drainage of perianal abscess with or without treatment of anal fistula. Cochrane Database Syst Rev. 2010;(7):CD006827.Google Scholar
  37. Meinero P, Mori L. Video-assisted anal fistula treatment (VAAFT): a novel sphincter-saving procedure for treating complex anal fistulas. Tech Coloproctol. 2012;16(1):111.PubMedCentralCrossRefGoogle Scholar
  38. Mitalas L, Gosselink M, Zimmerman D, Schouten R. Repeat Transanal Advancement Flap Repair: Impact on the Overall Healing Rate of High Transsphincteric Fistulas and on Fecal Continence. Diseases of the Colon & Rectum. 2007;50(10):1508–1511.CrossRefGoogle Scholar
  39. Mizrahi N, Wexner SD, Zmora O, et al. Endorectal advancement flap: are there predictors of failure? Dis Colon Rectum. 2002;45(12):1616–21.CrossRefPubMedGoogle Scholar
  40. Nelson R. Anorectal abscess fistula: what do we know? Surg Clin North Am. 2002;82(6):1139–51.CrossRefPubMedGoogle Scholar
  41. Ommer A, Herold A, Joos A, et al. Fistula plug in the treatment of high anal fistulas–initial results from a German multicenter-study. Ger Med Sci. 2012;10:13.Google Scholar
  42. O’Riordan JM, Datta I, Johnston C, Baxter NN. A systematic review of the anal fistula plug for patients with Crohn’s and non-Crohn’s related fistula-in-ano. Dis Colon Rectum. 2012;55(3):351–8.CrossRefPubMedGoogle Scholar
  43. Parks AG, Gordon PH, Hardcastle JD. A classification of fistula in ano. Br J Surg. 1976;63:1.CrossRefPubMedGoogle Scholar
  44. Present DH, Rutgeerts P, Targan S, et al. Infliximab for the treatment of patients with Crohn’s disease. N Engl J Med. 1999;340:1398–405.CrossRefPubMedGoogle Scholar
  45. Quah HM, Tang CL, Eu KW, et al. Meta-analysis of randomized clinical trials comparing drainage alone vs primary sphincter-cutting procedures for anorectal abscess-fistula. Int J Colorectal Dis. 2006;21(6):602–9.CrossRefPubMedGoogle Scholar
  46. Ramanujam PS, Prasad ML, Abcarian H, et al. Perianal abscesses and fistulas. A study of 1023 patients. Dis Colon Rectum. 1984;27(9):593–7.CrossRefPubMedGoogle Scholar
  47. Ratto C, Litta F, Parello A, et al. Gore Bio-A® Fistula Plug: a new sphincter-sparing procedure for complex anal fistula. Colorectal Dis. 2012;14(5):e264–9.CrossRefPubMedGoogle Scholar
  48. Ratto C, Litta F, Parello A. Fistulotomy with end-to-end primary sphincteroplasty for anal fistula: results from a prospective study. Dis Colon Rectum. 2013;56(2):226–33.CrossRefPubMedGoogle Scholar
  49. Read DR, Abcarian H. A prospective survey of 474 patients with anorectal abscess. Dis Colon Rectum. 1979;22:566–8.CrossRefPubMedGoogle Scholar
  50. Rojanasakul A, Pattanaarun J, et al. Total anal sphincter saving technique for fistula-in-ano; The ligation of intersphincteric fistula tract. J Med Assoc Thai. 2007;90(3):581–6.PubMedGoogle Scholar
  51. Schwandner O. Video-assisted anal fistula treatment (VAAFT) combined with advancement flap repair in Crohn’s disease. Tech Coloproctol. 2013;17(2):221–5.CrossRefPubMedGoogle Scholar
  52. Schwandner O, Stadler F, Dietl O, et al. Initial experience on efficacy in closure of cryptoglandular and Crohn’s transsphincteric fistulas by the use of the anal fistula plug. Int J Colorectal Dis. 2008;23(3):319–24.CrossRefPubMedGoogle Scholar
  53. Schwartz DA, Pemberton JH, Sandborn WJ. Diagnosis and treatment of perianal fistulas in Crohn disease. Ann Intern Med. 2001;135:906–18.CrossRefPubMedGoogle Scholar
  54. Sheikh P, Baazka A. Management of fistula in ano- the current evidence. Indian J Surg. 2014;76(6):482–6.CrossRefPubMedGoogle Scholar
  55. Sirikurnpiboon S, Burin A, Jivapaisarnpong P. Ligation of intersphincteric fistula tract and its modification: results from treatment of complex fistula. World J Gastrointest Surg. 2013;5(4):123–8.PubMedCentralCrossRefPubMedGoogle Scholar
  56. Sonoda T, Hull T, Piedmonte MR, Fazio VW. Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement flap. Dis Colon Rectum. 2002;45(12):1622–8.CrossRefPubMedGoogle Scholar
  57. Spencer JA, Chapple K, Wilson D, et al. Outcome after surgery for perianal fistula: predictive value of MR imaging. AJR Am J Roentgenol. 1998;171:403–6.CrossRefPubMedGoogle Scholar
  58. Stewart MP, Laing MR, Krukowski ZH. Treatment of acute abscesses by incision, curettage and primary suture without antibiotics: a controlled clinical trial. Br J Surg. 1985;72:66–7.CrossRefPubMedGoogle Scholar
  59. Sultan AH, Kamm MA, Hudson CN, et al. Anal sphincter disruption during vaginal delivery. N Engl J Med. 1993;329:1905–11.CrossRefPubMedGoogle Scholar
  60. Takayuki T, Makoto M, Yoshiaki T, et al. Evidence based treatment strategy of anorectal sepsis and anal fistula. Nippon Doncho Konmonbyo Gakki Zasshi. 2008;61(7):364–77.CrossRefGoogle Scholar
  61. Tan KK, Lee PJ. Early experience of reinforcing the ligation of the intersphincteric fistula tract procedure with a bioprosthetic graft (BioLIFT) for anal fistula. ANZ J Surg. 2013;84(4):280–3.CrossRefPubMedGoogle Scholar
  62. Tan KK, Tan IJ, Lim FS, et al. The anatomy of failures following the ligation of intersphincteric tract technique for anal fistula: a review of 93 patients over 4 years. Dis Colon Rectum. 2011;54(11):1368–72.CrossRefPubMedGoogle Scholar
  63. Tozer P, Sala S, Cianci V, et al. Fistulotomy in the tertiary setting can achieve high rates of fistula cure with an acceptable risk of deterioration in continence. J Gastrointest Surg. 2013;17:1960–5.CrossRefPubMedGoogle Scholar
  64. van Onkelen RS, Gosselink MP, Schouten WR. Is it possible to improve the outcome of transanal advancement flap repair for high transsphincteric fistulas by additional ligation of the intersphincteric fistula tract? Dis Colon Rectum. 2012;55(2):163–6.CrossRefPubMedGoogle Scholar
  65. Vasilevsky CA, Gordon PH. The incidence of recurrent abscesses or fistula-in-ano following anorectal suppuration. Dis Colon Rectum. 1984;27:126–30.CrossRefPubMedGoogle Scholar
  66. Vial M, Parés D, Pera M, Grande L. Faecal incontinence after seton treatment for anal fistulae with and without surgical division of internal anal sphincter: a systematic review. Colorectal Dis. 2010;12(3):172–8.CrossRefPubMedGoogle Scholar
  67. Wallin UG, Mellgren AF, Madoff RD, Goldberg SM. Does ligation of the intersphincteric fistula tract raise the bar in fistula surgery? Dis Colon Rectum. 2012;55(11):1173–8.CrossRefPubMedGoogle Scholar
  68. Whiteford MH, Kilkenny J, Hyman N, et al. Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised). Dis Colon Rectum. 2005;48:1337–42.CrossRefPubMedGoogle Scholar
  69. Yeung JM, Simpson JA, Tang SW, et al. Fibrin glue for the treatment of fistulae in ano-a method worth sticking to? Colorectal Dis. 2010;12(4):363–6.CrossRefPubMedGoogle Scholar

Copyright information

© Springer India 2016

Authors and Affiliations

  1. 1.Department of Colorectal SurgerySaifee HospitalMumbaiIndia
  2. 2.Consultant Minimal Access, Colorectal and General SurgeryRajawadi HospitalMumbaiIndia

Personalised recommendations