Clinical Practice Guidelines for Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula (ASCRS, 2022)

American Society of Colon and Rectal Surgeons

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

August 08, 2022

Clinical practice guidelines on the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula from the American Society of Colon and Rectal Surgeons (ASCRS) were published in August 2022 in Diseases of the Colon & Rectum.[1]

For patients with an acute anorectal abscess, prompt treatment with incision and drainage is recommended. Antibiotics are generally reserved for those who have concurrent cellulitis, systemic infection, or immunosuppression.

Endorectal advancement flap procedures are recommended for patients with anal fistulas. For those who have a simple anal fistula and normal anal sphincter function, a lay-open fistulotomy may be used.

Minimally invasive surgery that involves endoscopy or laser closure may be used to treat anal fistulas. The short-term healing rates have been promising; however, the long-term healing and recurrence rates remain unknown.

Because of the generally poor healing rates associated with fistula plugs and fibrin glue, they are considered relatively ineffective treatments for anal fistulas.

For patients with complex cryptoglandular anal fistulas, a cutting seton may be appropriate; however, this technique can lead to functional impairment.

Benign, minimally symptomatic rectovaginal fistulas can be treated with nonsurgical approaches, such as baths, wound care, antibiotics (in patients with infection), and stool-bulking fiber supplements, typically for about 3-6 months. Nonsurgical management may also be appropriate for other benign, minimally symptomatic fistulas.

For the repair of a rectovaginal fistula, an endorectal advancement flap with or without sphincteroplasty is recommended.

A combination of surgery and drug therapy is recommended for the management of anorectal fistulas associated with Crohn disease. The best-studied drugs in this setting are infliximab and adalimumab.

Endorectal advancement flaps and ligation of the intersphincteric fistula tract are options for the management of anal fistulas in patients with Crohn disease. Draining setons may also be used for long-term control of fistulizing anorectal Crohn disease.

For select patients with Crohn disease who have refractory anorectal fistulas, local treatment with mesenchymal stem cells is considered effective and safe. However, this approach is not widely available.

For more information, please go to Anal Fistulas and Fissures, Anal Fistulotomy, Anorectal Abscess, Fistula-in-Ano, Rectovaginal Fistula, and Crohn Disease.


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