Clinical Review

Management of anal fistula

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6705 (Published 15 October 2012) Cite this as: BMJ 2012;345:e6705

This article has a correction. Please see:

  1. Jonathan Alastair Simpson, specialist registrar in colorectal surgery,
  2. Ayan Banerjea, colorectal consultant,
  3. John Howard Scholefield, professor of surgery
  1. 1Division of Digestive Diseases, Queen’s Medical Centre Campus, Nottingham University Hospitals, Nottingham NG7 2UH, UK
  1. Correspondence to: J A Simpson alastairsimpson{at}hotmail.com
  • Accepted 1 October 2012

Summary points

  • A high index of suspicion of anal fistula is needed when examining patients with a perianal abscess or sepsis

  • All fistulas consist of a primary track but may also have secondary extensions

  • Complex fistulas need careful assessment and investigation; many months of treatment and several procedures may be needed before resolution

  • Some patients are best treated with a seton alone

  • Counsel patients who consent to surgery of the anal sphincter about possible post-procedural incontinence

Anal fistula is part of the spectrum of perianal sepsis. It is a chronic condition that may present de novo or after an acute anorectal abscess. Anal fistula causes a variety of prolonged or intermittent symptoms including pain, discharge, and social embarrassment.

The goals of management are to eradicate the fistula and prevent recurrence while maintaining continence. Simple anal fistula may be easy to treat, but complex cases may require several procedures over months (or years). In some cases, treatment may result in a stoma formation or incontinence, which has a profound effect on the patient’s quality of life.

This article aims to provide a pragmatic overview of this often poorly understood condition and enable primary care doctors and other non-specialists to appreciate the common management pathways that their patients might experience.

Sources and selection criteria

We searched PubMed and the Cochrane Library for clinically relevant studies using the search terms anal fistula and perianal sepsis. We consulted guidelines from the National Institute for Health and Clinical Excellence, in addition to both the Association of Surgeons of Great Britain and Ireland and the Association of Coloproctology clinical guidance.

What is an anal fistula?

A fistula is defined as an abnormal communication between two epithelial surfaces. Anal fistula is a communication between the anorectal canal and the perianal skin that is lined with granulation tissue. It may be useful to consider it as a tunnel during …

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