Getting Surgery for a Perianal Fistula

Medically reviewed by: Eiman Firoozmand, MD
Last modified on November 6th, 2023

Surgery is a scary word. But sometimes, it’s the most effective option out there. If your healthcare provider has recommended surgery for your perianal fistula, you’ve come to the right place.

That’s because, in this blog post, we’ll answer all your questions about getting surgery for a perianal fistula. But first, let’s briefly review what it really means.

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What is a perianal fistula?

A perianal fistula is a small tunnel that forms between the anus and the skin near it. The most common cause of a perianal fistula is an infection of the anal gland. But there are also other causes, such as:

Symptoms can range from anal itching, burning, and pain to drainage of pus or blood. You might even experience fever or chills.

Getting Surgery for a Perianal Fistula

Types of fistulas

There are many types of perianal fistula, but they’re broadly divided into high fistulas and low fistulas. The internal opening of a high fistula is located above something called the dentate line. For low fistulas, this opening is located below the dentate line.

The dentate line is a line of tissue that separates the anal canal from the rectum. It’s important to know where your fistula is located, as it will determine the kind of surgery you’ll need.

How is a perianal fistula treated?

A perianal fistula is treated with a combination of drugs and surgery.

Anal abscess treatment

A perianal fistula begins as a rectal abscess.  This is a collection of pus in the lining of the anal canal or rectum.  Usually, patients present to the doctor with acute pain and fever. This is caused by the perianal abscess, which is very common in people with a fistula. In this case, it’s important first to treat the abscess and then the fistula.

Types of anal abscesses

Types of anal abscesses (source)

A perianal abscess is treated by a procedure called incision and drainage, where a doctor makes a cut in the abscess and drains out the pus. This allows the infection to heal faster.

After the procedure, you may be recommended stool softeners, pain-killers, Sitz baths, and even antibiotics in some cases. 

Once the inflammation around your anal area has completely healed, the doctor will then move on to performing a definitive surgical procedure to close the fistula.  It is important to note that not all abscesses become chronic fistulas.  Some heal and do not return.  This can occur in 50% of patients.

Surgical treatment for perianal fistula

The current standard surgical treatment for perianal fistulas is called a fistulotomy. This involves making an incision along the length of your fistula and then cutting it open, which results in the complete removal of the fistula.

However, this procedure is not without risks. Complications such as incontinence, bleeding, infection, and poor wound healing may occur, especially if the fistula involves a large portion of the anal sphincter muscle. 

In this case, your doctor may place a seton, which is a thread-like material, around the fistula and leave it in place for several weeks. This is done to slowly allow the body to heal and reduce the risk of incontinence.  Also, if the fistula involves a large amount of anal sphincter, the surgeon will not want to cut all of that muscle for fear that the patient will become incontinent.  This would mean losing a lesser or greater amount of control of the anal sphincter and thus, losing control of sool, liquid or gas.

Surgical treatment for perianal fistula


Another commonly performed procedure is called an endorectal advancement flap (ERAF). This is where the surgeon uses the inner lining of your rectum to cover the internal opening of the fistula. The goal is to prevent communication between the internal and external openings and promote fistula healing. This avoids injury to the sphincter complex and has low incontinence risks.

LIFT — ligation of intersphincteric fistula tract — is a relatively new procedure to treat fistulas, but there are not a lot of studies to determine how effective it is. This involves dividing the fistula and tying off the ends, allowing the tissues to heal with almost no risk of incontinence.

Crohn’s fistula treatment

In case you have a perianal fistula due to Crohn’s disease, your healthcare provider will ensure your Crohn’s disease is under control before going for surgery. 

Unfortunately, people with Crohn’s tend to get recurrent fistulas, even after treatment. This may prompt your doctor to perform a procedure called panproctocolectomy, where the entire colon and rectum are removed.

Sometimes, your healthcare provider may inject something called ‘fibrin glue’ into your fistula. This promotes the formation of a clot inside the fistula, closing it off mechanically. Fibrin glue injection is thought to be a simple, effective, and safe procedure for perianal fistulas due to Crohn’s disease. Success rates can be highly variable.

Fortunately, there are studies going on to see how effective drugs like infliximab and adipose-derived stem-cell therapy are in treating fistulas due to Crohn’s disease. 

In one study looking at infliximab, a response rate of 50-60% was seen for perianal fistulas associated with Crohn’s disease.

But of course, these therapies are still in their experimental stages, and it’s unlikely that your healthcare provider is going to recommend them.

How urgent is fistula surgery?

Surgery for a fistula may not be as urgent as surgery for a heart attack. But that doesn’t mean that it should be delayed. 

Plus, in cases of an abscess, doctors usually recommend immediate treatment. In cases where there is no abscess, it’s possible to wait for a few weeks before going in for surgery.

It’s also important to note that doctors don’t usually perform surgery if your fistula is not causing symptoms. In this case, surgery can be delayed and performed only once symptoms arise.

How long does perianal fistula surgery take?

How long a perianal fistula surgery takes depends on the procedure being performed.

A fistulotomy is usually performed as an outpatient procedure, meaning you can go home the same day. The procedure takes around an hour to perform, but you should also account for pre-operative preparation and post-operative recovery time.

For example, you may be given rectal irrigation using an enema on the morning of the operation. You may also require antibiotics before the procedure, as well as an evaluation for anesthesia fitness. 

Keep in mind that although fistulotomy is usually an outpatient procedure, you may need general anesthesia in an operating room if your fistula is large and complex. In this case, it can take longer to perform fistula surgery.

Just like a fistulotomy, seton placement is also an outpatient procedure that takes around an hour to perform.

How long is hospital stay for fistula surgery?

Most fistula surgeries are performed on an outpatient basis, meaning you won’t require a hospital stay. However, this will depend on the type of procedure being performed, your overall health, and the complexity of the fistula.

If your fistula is large and complex, you may be required to stay in the hospital for a few days. This is to ensure that your wound is healing properly and monitor for complications. 

No matter what the procedure, it’s important to follow your doctor’s instructions and recovery plan. This will ensure that you make a full and speedy recovery from your surgery.

How painful is fistula surgery?

Fistula surgery itself is not painful. This is because the area will be numbed before the procedure.

However, you may experience some pain and discomfort in the days following the surgery. This is due to the inflammation and swelling of the area. Your doctor may prescribe pain medicine to help manage this discomfort.

It’s also important to follow your doctor’s instructions for post-operative care. This may include taking warm baths, using stool-bulking agents like bran, and resting and avoiding any strenuous activities. Doing this will help reduce the amount of post-operative pain and discomfort you experience.

Overall, the extent of your post-operative pain will depend on the type of procedure that was performed and the complexity of your fistula. 

Plus, if you develop complications, such as thrombosed hemorrhoids, fecal impaction, or delayed wound healing, your pain may be greater than usual. In all of these cases, it’s important to seek immediate medical attention.

Can you live without fistula surgery?

Yes, you can live without fistula surgery. This is especially true if you have no symptoms, in which case your doctor may wait and watch your condition instead of jumping into surgery.

But once you develop symptoms, it’s best to have the condition treated. And the most effective current treatment for perianal fistulas is surgery. If you delay treatment, you may develop complications like sepsis (a life-threatening situation where there is widespread inflammation in the body) and anal cancer.

Can fistula return after surgery?

Unfortunately, fistulas can return after surgery. How often this happens depends on the procedure performed.

For example, the rate of return for standard fistulotomy is anywhere between 0% and 18%, and for a LIFT procedure, it’s somewhere around 22%. For seton placement, it’s between 0% and 17%, while for ERAF, it’s between 8% and 40%.

This means it’s relatively rare for a fistula to come back after surgery. However, it’s important to know that it is still possible and you should be aware of the signs and symptoms of a recurrent fistula.

The most common signs and symptoms are persistent drainage from the wound, pain at the surgical site, and an increase in the size of the wound. If you experience any of these symptoms, it’s important to contact your doctor immediately.

Surgery for anal fistula simplified

We hope this article has cleared up any confusion you may have had about surgery for an anal fistula. To summarize:

Fistula surgery is a highly effective and safe way to treat perianal fistulas. The procedure can usually be done on an outpatient basis, but more complex fistulas may require a hospital stay. 

Pain during and after the surgery is usually minimal, and post-operative pain can be managed with pain medication. And while the risk of recurrence is relatively low, it’s still possible.

If you have any questions or concerns about anal fistula surgery, don’t hesitate to reach out to us. We will be happy to answer your questions!

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