Can an anal fistula heal without surgery, or is surgery always needed?

Name: Can an anal fistula heal without surgery, or is surgery always needed?
Published: 2026-10-05

In adults with a cryptoglandular anal fistula (fistula-in-ano), does non-surgical management (e.g., antibiotics, observation, seton drainage alone, or other conservative measures) achieve fistula closure and prevent recurrence compared with surgical treatment (fistulotomy, LIFT, advancement flap, or other operative repair)?

Compiled 2026-10-05 · checked 2026-10-05 · next 2026-11-05 · automated review, how it works

Bottom line

In adults with a typical (cryptoglandular) anal fistula, the little evidence available suggests the tunnel usually does not close on its own, and non-surgical options may work less reliably than surgery.

Only two studies actually address this exact comparison, and both are weak: one is an expert opinion piece with no original data, and the other combines older low-quality studies rather than testing people directly. One reports that fistulas rarely heal by themselves, and the other found a non-surgical fistula plug failed more often than surgery. Because no trial has properly tested this, and other smaller studies don't all agree, this is a signal of possible harm from relying on non-surgical treatment, not a settled answer.

How certain

Very low

Only observational evidence addresses this question (2 studies). The studies disagree with one another, so the overall certainty is lower than any single one of them.

What it shows

Signal of harm

2 studies reported harm or tissue damage, including laboratory evidence.

studies found: 80studies found
randomised trial: 1randomised trial
people studied: 12,241people studied
reviews of trials: 8reviews of trials
years covered: 1979–2026years covered

Read this first

A combined analysis of earlier studies found that a non-surgical fistula plug was followed by the fistula coming back more often than with surgery (about 62 out of 100 people versus about 47 out of 100).
A review of fistula treatment states these tunnels usually do not close by themselves, meaning ongoing infection, drainage, or abscess can persist if surgery is delayed or avoided.

What the research shows

Fistula healing or closure rate
The two studies that directly address adults with this type of fistula both raise concern: one states these fistulas rarely close on their own, and the other found a non-surgical fistula plug closed the fistula less often than surgery did.[1,2]
Possible harm
Recurrence rate at 12 months
The meta-analysis reported overall recurrence (fistula coming back) but not specifically at the 12-month mark, so there isn't a clean answer for this exact timepoint.[1]
Insufficient evidence
Time to complete healing
Neither of the two studies that directly address this question reported how long healing took with non-surgical versus surgical treatment.
Not studied
Fecal incontinence rate
The meta-analysis found no significant difference in loss of bowel control between the non-surgical fistula plug and surgery, so avoiding surgery did not appear to lower this particular risk.[1]
No improvement shown
Need for repeat or salvage surgery
Because the non-surgical fistula plug failed more often than surgery, and a review describes most fistulas eventually needing an operation, non-surgical treatment appears more likely to be followed by a later surgery.[1,2]
Possible harm
Persistent discharge or abscess recurrence
Neither of the two studies that directly address this question measured ongoing discharge or repeat abscesses after treatment.
Not studied

Important limitations

Only two sources address this comparison in adults with cryptoglandular anal fistula: a narrative review (Chirurg 2012) that makes general clinical statements with no original patient data, study design, or numbers, and a meta-analysis of 428 patients (Saudi Med J 2012) that found a fistula plug had higher recurrence than conventional surgery (62.1% vs 47%). Neither compares true non-surgical management, such as antibiotics or watchful waiting, with surgery: the review gives no data at all, and the meta-analysis compares two procedures (plug versus surgery), not surgery versus no treatment.[1,2]
One of the two key sources is a narrative review with no original patient data, numbers, or methodology — it states a clinical impression rather than measured results.[1]
The other key source is a meta-analysis of studies comparing a fistula plug with conventional surgery, rated low quality overall; the abstract does not report on differences between the included studies (heterogeneity), their risk of bias, or how long patients were followed.[1]
Most of the 80 related studies found in this search involve children, people with Crohn's disease, or other kinds of fistula entirely (such as rectovaginal or rectourethral fistula after prostate surgery), so they cannot be used to answer this question for adults with a standard anal fistula.[1,2,3,4,5]
Smaller separate case series of non-surgical treatments (such as chemical or plug-based methods) report healing in roughly half to three-quarters of patients, which conflicts with the harm signal from the two directly relevant studies — this disagreement is part of why overall certainty is rated very low.[1,2,3]

Why people try it

Surgery near the anal sphincter (the muscle ring that controls bowel movements) sounds frightening, and people worry about losing control of bowel movements afterward.
Non-surgical options like antibiotics, chemical solutions, or a plug are marketed as a way to fix the problem without an operation or anaesthesia.
Some people hope the fistula will simply close on its own if they keep the area clean and wait.
Avoiding surgery means avoiding time off work, a hospital visit, and the cost of an operation.

What the studies found

Found a benefit36 · 45%
Found no clear effect7 · 9%
Mixed or unclear35 · 44%
Found possible harm2 · 3%

What kind of studies

Case series27 · 34%
Retrospective24 · 30%
Narrative review12 · 15%
Systematic review6 · 8%
Prospective cohort5 · 6%
Meta-analysis2 · 3%
Guideline2 · 3%
Animal study1 · 1%
Randomised trial1 · 1%

The studies that decided it

Attaallah et al. 2021
Chemical Ablation for Treating Anal Fistulas without Surgical Intervention: Long-Term Results
Fistula healed without surgery in some patients.Prospective cohortLow quality
186 people50 (7-64) months
44% of patients achieved complete clinical healing; healing was more likely with intermittent discharge and fistulas without abscesses or secondary tracts
Who was studied
Adults with symptomatic anal fistula
What they received
Chemical ablation of the fistula tract using 5% silver nitrate solution
Compared with
No comparator group; single-arm study
Main outcome
Rate of complete clinical healing of the fistula after long-term follow-up
Quality
This was a single-arm study without a surgical comparison group, so it cannot show whether chemical treatment works better or worse than surgery.
Limitations
No control or comparator group was used; the abstract does not mention blinding or randomization.
Taken word for word from the abstract
- population Adult patients with symptomatic perianal fistula
- intervention The fistula tract was irrigated with a 5% silver nitrate solution.
- comparator A total of 186 patients with anal fistula were analysed.
- primaryOutcome The primary outcome measured in this study was the rate of clinical healing after long-term follow-up.
- result 82 (44%) patients had complete clinical healing during a median follow-up time of 50 (7-64) months
- result Patients with intermittent discharge had a significantly higher rate of complete clinical healing than those with continuous discharge (P < .04).
- result Fistulas without abscesses or secondary tracts had a significantly higher rate of complete clinical healing than the other types (P = .007).
- n A total of 186 patients with anal fistula were analysed.
- followUp median follow-up time of 50 (7-64) months
Surg Innov · PMID 33787391 · Read it on PubMed ↗
Iqbal et al. 2019
Outcome Of Use Of 1% Silver Nitrate In Patients With Low Lying Perianal Fistula
Most fistulas healed without surgery.Case seriesLow quality
76 people10 weeks
58 out of 76 patients (76.3%) achieved complete healing without surgery
Who was studied
patients with low lying perianal (anal) fistula
What they received
irrigation of the fistula tract with 1% silver nitrate solution
Compared with
none (no comparison group, single-arm study)
Main outcome
complete clinical healing, defined as no symptoms for 10 weeks in a row
Quality
This was a small, single-center study with no control group, so it can't prove silver nitrate itself caused the healing.
Limitations
No comparator/control group; single-arm design; 3 of 79 patients lost to follow-up; short follow-up period of 10 weeks.
Taken word for word from the abstract
- population patients with low lying perianal fistula
- intervention irrigation of the fistula tract with 1% of silver nitrate solution
- comparator non-surgical procedure for fistula in ano
- primaryOutcome Outcome measure were cessation of the symptoms for consecutive 10 weeks.
- result Out of 76 patients, 58 (76.3%) patients showed complete clinical healing while 18 (23.68%) of patients showed failure to clinical healing.
- n Seventy-six patients were assessed and underwent irrigation using this 1% of silver nitrate solution.
J Ayub Med Coll Abbottabad · PMID 31535505 · Read it on PubMed ↗
Pérez Lara et al. 2019
Can Perianal Fistula Be Treated Non-surgically with Platelet-Rich Fibrin Sealant?
Non-surgical plug worked about as well.RetrospectiveLow quality
size not given2019
the outpatient non-surgical approach gave results similar to standard surgical plug insertion with traditional curettage, while a different surgical technique using graduated curettes did significantly better than both
Who was studied
people with anal (perianal) fistula
What they received
platelet-rich fibrin plug inserted in outpatient clinic without surgery, anaesthesia, curettage or closing the internal opening
Compared with
platelet-rich fibrin plug inserted surgically under anaesthesia, with two different curettage/closure techniques
Main outcome
whether the fistula healed (outcome success) and complication/continence rates
Quality
this is a non-randomised comparison of three groups without reported patient numbers, so it is easy for differences between groups to bias the results.
Limitations
no randomisation described, sample size not reported, and differences in outcomes between techniques reduce certainty about the non-surgical method's true effect.
Taken word for word from the abstract
- population anal fistula
- intervention for those in group C, the plug was inserted during outpatient consultation, without anaesthesia, without curettage and without closure of the internal orifice
- comparator for the patients in group A, the plug was surgically inserted, under anaesthesia, and traditional methods were used to curette the fistula tract and close the internal orifice; for those in group B, the plug was surgically inserted, under anaesthesia, after curettage of the fistula tract using a graduated set of cylindrical curettes, and the internal orifice was closed as before
- primaryOutcome There were no significant differences in morbidity or postoperative continence. However, there was a statistically significant difference in the outcomes achieved
- result there was a statistically significant difference in the outcomes achieved, in favour of group B, while groups A and C obtained similar results
J Gastrointest Surg · PMID 30187327 · Read it on PubMed ↗
Heitland 2012
[Perianal fistula and anal fissure]
Fistulas don't heal without treatment.Narrative reviewLow quality
size not given2012
perianal fistulas do not heal on their own; treatment ranges from surgery to conservative options like fibrin glue or plug
Who was studied
people with anal fistula caused by gland infection
What they received
no treatment / conservative options like fibrin glue or plug
Compared with
surgical operation
Main outcome
whether the fistula heals and whether incontinence develops
Quality
this is a narrative review summarizing opinion rather than presenting original study data or evidence quality.
Limitations
no study design, sample size, or data presented; abstract gives general clinical statements only
Taken word for word from the abstract
- population Perianal abscesses are caused by cryptoglandular infections
- intervention a conservative treatment with fibrin glue or a plug
- comparator a more aggressive approach (operation)
- primaryOutcome Definitive healing and the development of incontinence are the most important key points
- result perianal fistulas will not heal on their own
Chirurg · PMID 23179514 · Read it on PubMed ↗
Pu et al. 2012
Fistula plug versus conventional surgical treatment for anal fistulas. A system review and meta-analysis
Plug heals worse than surgery.Meta-analysisLow quality
428 people2012
fistula plug had a higher recurrence rate than surgery (62.1% versus 47%), with no significant difference in incontinence between the two
Who was studied
patients with anal fistulas
What they received
fistula plug treatment
Compared with
conventional surgical treatment
Main outcome
fistula coming back (recurrence) and fecal incontinence
Quality
Only 2 randomized trials and 3 retrospective studies with 428 patients total, so results are not very reliable.
Limitations
Abstract does not report study heterogeneity, follow-up duration, or risk of bias assessment.
Taken word for word from the abstract
- n A total of 428 patients were included in our study.
- population anal fistulas
- intervention anal fistula plug
- comparator conventional surgical treatment
- primaryOutcome To evaluate the recurrence and fecal incontinence of anal fistula plug versus conventional surgical treatment for anal fistulas.
- result The recurrence rate was higher in those patients who accept fistula plug treatment (62.1% versus 47%) (p=0.004).
- result This meta-analysis failed to find a statistically significant difference in incontinence rate between conservative treatment and conventional surgical treatment.
Saudi Med J · PMID 22964807 · Read it on PubMed ↗
de Parades et al. 2008
[Cryptoglandular anal fistulas]
Surgery needed; antibiotics don't work.Narrative reviewVery low qualityRelated question
size not given2008
surgical fistulotomy is very effective at curing the fistula but carries some risk of anal incontinence; antibiotics are not useful except in special cases
Who was studied
adults with anal fistulas caused by infected anal glands
What they received
surgical treatment of the fistula (fistulotomy, sphincter-sparing flap, fibrin glue)
Compared with
antibiotic therapy alone
Main outcome
cure of the fistula (drying up discharge, avoiding recurrence) while preserving continence
Quality
This is a narrative overview of treatment approaches with no study data, comparison groups, or outcome numbers reported.
Limitations
No patient numbers, no study design, no comparative data given; it is a general description of management rather than a trial testing whether surgery can be avoided.
Taken word for word from the abstract
- population Cryptoglandular anal fistulae are the most frequently occurring form of perianal sepsis.
- intervention surgical fistulotomy
- intervention sphincter preserving techniques using the advancement of a covering flap of rectal mucosa and the injection of fibrin glue
- comparator Antibiotic therapy is not of use in initial management except in special cases.
- primaryOutcome aims to dry up the purulent discharge and avoid recurrence of the abscess
- result These techniques are very effective in terms of eradication of the problem but there is sometimes a risk of anal incontinence.
Rev Prat · PMID 19143149 · Read it on PubMed ↗

What actually helps, on this site

Treatments Dr. Kamrava performs for this:

Fistulotomy

More about the condition:

All 80 studiesEvery study that answered the question, with its design, size and result.

The other 74 studiesEverything else the search returned, including anything retracted.

Yuan et al. 2026
Age-stratified management of pediatric perianal abscesses: a proposed framework integrating the "Developmental Healing Axis"
Conservative care may work in young children.Narrative reviewVery low qualityRelated question
size not given2026
conservative strategies often effective in infants/young children, while surgical drainage in older children carries more fistula risk
Who was studied
children with perianal abscesses
What they received
conservative treatment (antibiotics and watchful waiting) versus surgical drainage
Compared with
surgical incision and drainage versus conservative management, varying by age
Main outcome
fistula formation and recovery after abscess treatment
Quality
this is a narrative review of pediatric abscesses (not established fistulas) with no systematic methodology or pooled data reported.
Limitations
abstract describes a conceptual review of abscess management in children, not a study of existing fistulas healing without surgery, and identifies its own evidence gaps needing future research.
Taken word for word from the abstract
- population Pediatric perianal abscesses represent a frequent yet underrecognized condition
- intervention Surgical interventions such as incision and drainage offer rapid symptom relief but may increase the risk of fistula formation, particularly in older children.
- comparator conservative strategies including antibiotic therapy and observation are often effective in infants and young children, reflecting their superior regenerative capacity
- primaryOutcome minimize recurrence, and prevent fistula development
- result Surgical interventions such as incision and drainage offer rapid symptom relief but may increase the risk of fistula formation, particularly in older children. In contrast, conservative strategies including antibiotic therapy and observation are often effective in infants and young children
Front Pediatr · PMID 42221001 · Read it on PubMed ↗
Borkowski et al. 2026
Predictors of Recurrence in Pediatric Perianal Abscess and Fistula-In-Ano: Insights From a 5-Year Surgical Cohort Study
Prior fistula predicts recurrence after surgery.RetrospectiveLow qualityRelated question
108 people2026
having a fistula-in-ano found at the first surgery predicted higher fistula recurrence (31.6% vs 10.1%), while abscess recurrence was not significantly different; antibiotics, abscess size, and symptom duration did not predict recurrence
Who was studied
children aged 0 to 17 with perianal abscess or fistula-in-ano
What they received
surgical incision and drainage, with some having an existing fistula-in-ano found during surgery
Compared with
patients without a fistula-in-ano found during initial surgery
Main outcome
recurrence of abscess or fistula after surgical treatment
Quality
this is a retrospective single-center review of only surgically treated patients without a non-surgical comparison group, so it can't show whether surgery is needed.
Limitations
Retrospective design, all patients received surgery as primary management, and ultrasound diagnosis of fistula was often inconclusive (67 cases with no definitive conclusion).
Taken word for word from the abstract
- n We retrospectively reviewed 108 pediatric patients (0-17 years) treated surgically for PA and/or FIA
- population pediatric patients (0-17 years) treated surgically for PA and/or FIA between January 2019 and February 2024
- intervention Inclusion criteria were PA diagnosis and incision and drainage as primary management.
- comparator Recurrence of PA was more frequent in those with initial FIA (36.8%) than without (24.7%)
- primaryOutcome This study aimed to evaluate recurrence rates after surgical treatment of PA and FIA and identify clinical factors associated with fistula formation
- result FIA recurrence was significantly higher in patients with initial FIA (31.6% vs 10.1%, P=0.024). Among 99 patients undergoing ultrasound, diagnostic accuracy for PA was 100%.
Med Sci Monit · PMID 41578630 · Read it on PubMed ↗
Alam et al. 2025
Does antibiotic therapy for anal abscess reduce the risk of fistula surgery? A retrospective study
Antibiotics after incision reduced recurrenceRetrospectiveLow qualityRelated question
109 peopleapproximately 30 months
absence of antibiotic therapy after incision was linked to higher recurrence; 18% of incision-alone patients had recurrence
Who was studied
adults with a first-time perianal abscess treated by incision
What they received
antibiotic therapy given after incision
Compared with
incision alone without antibiotics
Main outcome
rate of patients requiring fistula surgery and/or experiencing abscess recurrence
Quality
This was a small retrospective study with only univariate analysis and no multivariate analysis due to insufficient data, so the finding is weak.
Limitations
Retrospective design, multivariate analysis not conducted due to insufficient data, and the study looked at abscess patients rather than confirmed fistula patients.
Taken word for word from the abstract
- n Among 109 patients (mean age 43 ± 13 years; 74 % male), 55 had incision alone, and 54 underwent fistula surgery.
- population We retrospectively included all patients presenting in 2019 with a first perianal abscess treated by incision under local anesthesia
- intervention with or without antibiotic therapy post-incision
- comparator The role of post-incision antibiotic therapy is also debated.
- primaryOutcome The primary outcome was the rate of patients requiring fistula surgery and/or experiencing abscess recurrence
- result absence of antibiotic therapy post-incision as predictive of recurrence with (OR 0.44) were predictive of recurrence
- result during which 18 % (10 patients) experienced abscess recurrence
- followUp The mean follow-up for patients with incision alone was approximately 30 months
Clin Res Hepatol Gastroenterol · PMID 41047078 · Read it on PubMed ↗
Acker et al. 2025
Management of Perianal Abscesses in Infants: A Systematic Review From the APSA Outcomes and Evidence-Based Practice Committee
Recurrence common whether treated with surgery or not.Systematic reviewLow qualityRelated question
size not given2025
About 37.5% of non-operative treatment failed initially; recurrence was about 21% after non-operative care and 24% after incision and drainage; fistula developed in about 21% after non-operative care versus 20% after drainage; recurrence after surgery for the fistula itself was about 7%
Who was studied
infants with perianal abscess or anal fistula
What they received
non-operative care (hygiene, sitz baths, antibiotics) or incision and drainage of abscess
Compared with
direct surgical treatment of the fistula (e.g., upfront fistulotomy)
Main outcome
whether the perianal disease resolved or came back, including fistula development
Quality
It pools findings from many small, lower-quality studies (level 3-4 evidence) in infants, so the numbers are rough estimates rather than strong proof.
Limitations
Includes only level 3-4 studies, time to resolution varied widely, and findings are specific to infants rather than the general population with anal fistula.
Taken word for word from the abstract
- population Management of infant perianal disease, including perianal abscess and fistula-in- ano (FIA)
- intervention nonoperative management (NOM) strategies (such as hygiene, sitz baths, and systemic antibiotics), operative intervention for abscess only (incision and drainage (I&D))
- comparator direct surgical management of the FIA (e.g. upfront fistulotomy)
- primaryOutcome Recurrence rate after initial success with NOM or I&D is approximately 21 % and 24 %, respectively.
- result Initial failure of NOM is approximately 37.5 %. Recurrence rate after initial success with NOM or I&D is approximately 21 % and 24 %, respectively. The rate of FIA development is approximately 21 % after NOM and 20 % after I&D. Recurrence after operative management of FIA, regardless of approach, is 7 %.
- n 31 manuscripts describing the expected course of perianal disease
J Pediatr Surg · PMID 40983150 · Read it on PubMed ↗
Arjafallah Goulet et al. 2025
Less combination therapy and more fistulotomy in perianal fistulizing Crohn's disease in the elderly
Similar healing with less aggressive treatment in elderlyRetrospectiveLow qualityRelated question
30 people2025
Fistula closure rates were about the same in older and younger patients even though older patients got less aggressive drug therapy and more fistulotomies
Who was studied
People over 60 with Crohn's disease who needed first-time surgery for an anal fistula, compared with matched younger patients
What they received
Less intensive combined drug therapy and more simple fistula-opening surgery (fistulotomy) in older patients
Compared with
More intensive combined drug therapy and more sphincter-sparing surgery in younger matched patients
Main outcome
Whether the anal fistula closed after treatment
Quality
This is a retrospective, matched comparison of surgical patients with Crohn's-related fistulas, not a trial testing surgery versus no surgery, so it can't show whether fistulas heal without surgery.
Limitations
Retrospective design, small elderly group (n=30), matched rather than randomized comparison, and all patients underwent surgery so there is no non-surgical comparison group.
Taken word for word from the abstract
- n 6% (n = 30) aged over 60 years at first surgery were included
- population all patients over 60 years old who underwent a first surgical intervention for anal fistula at two medical centers were included
- comparator two younger patients who underwent the same surgical procedure during the same period in the same centers were matched for comparison
- intervention combined therapy and anti-TNF alpha optimization less often (p = 0.0002 and p = 0.0001); iii) fewer surgical interventions: 3 vs 4.5, p = 0.008; iv) sparing surgery less frequently: 30% vs 58%, p = 0.01; v) fistulotomy more often: 27% vs 5%, p = 0.003
- primaryOutcome The rates of anal fistula closure were comparable between the two groups
- result The rates of anal fistula closure were comparable between the two groups: 60% vs 62%, p = 0.93
Int J Colorectal Dis · PMID 40926129 · Read it on PubMed ↗
Chen et al. 2025
Treatment of perianal abscess and anal fistula in infants: a systematic review
Similar healing with or without surgery.Systematic reviewLow qualityRelated question
1,770 people2025
similar cure rates: 75.2% cured with conservative treatment vs 73.4% cured with surgery
Who was studied
infants with perianal abscess or anal fistula
What they received
conservative (non-surgical) treatment
Compared with
surgical treatment
Main outcome
cure rate and recurrence of abscess or fistula
Quality
it pools 18 retrospective studies without randomization, so differences between groups could be due to other factors.
Limitations
all included studies were retrospective; the abstract does not describe randomization or control for confounding factors between conservative and surgical groups
Taken word for word from the abstract
- n eighteen retrospective studies, encompassing 1,770 patients, were analyzed
- population The optimal treatment approach for perianal abscess (PA) and fistula-in-ano (FIA) in infants remains a subject of debate.
- intervention Of the 702 cases (38.7%) that underwent conservative treatment, 528 cases (75.2%) achieved a cure
- comparator among the 1,068 cases (61.3%) that received surgical interventions, 784 cases (73.4%) were cured
- primaryOutcome 528 cases (75.2%) achieved a cure, while 174 cases (24.8%) were unsuccessful, with 93 experiencing PA recurrence and 81 developing FIA
- result The available studies indicate minimal differences in the cure and recurrence rates of PA and FIA between the conservative and surgical treatment groups.
Front Surg · PMID 40585484 · Read it on PubMed ↗
Curtis et al. 2025
Fistulae Secondary to Vaginal Pessary Use for Pelvic Organ Prolapse: A Systematic Review
Many pessary fistulas healed without surgery.Systematic reviewLow qualityRelated question
76 people2025
conservative management resulted in size reduction or resolution in 69% of fistulae, while surgical repairs were also often successful
Who was studied
women with pelvic organ prolapse who developed fistulas from using a vaginal pessary
What they received
non-surgical (conservative) management of the fistula
Compared with
surgical repair of the fistula
Main outcome
whether the fistula healed or resolved
Quality
the evidence comes mostly from case series and reports plus two retrospective studies, which carry high risk of bias and cannot reliably compare treatments
Limitations
included mostly case series/reports with risk of bias assessed as significant, retrospective design, and this concerns pessary-related urogenital/rectovaginal fistulas rather than anal fistula
Taken word for word from the abstract
- population patients using pessary for POP
- intervention Conservative management resulted in size reduction or resolution in 69% of fistulae: this approach should be considered.
- comparator Vaginal (88%) and abdominal (100%) vesicovaginal fistula repairs were successful.
- primaryOutcome Conservative management resulted in size reduction or resolution in 69% of fistulae
- result Conservative management resulted in size reduction or resolution in 69% of fistulae: this approach should be considered.
- n 76 fistulae (34 urogenital, 42 rectovaginal)
Int Urogynecol J · PMID 39833536 · Read it on PubMed ↗
Palma García et al. 2026
Continuous endoscopic manual suturing for colorectal anastomotic fistula closure
Suturing failed, surgery still needed.Case seriesVery low qualityRelated question
1 peopleone month of hospitalization
the fistula closed at first but then reopened, and surgery was ultimately needed
Who was studied
a man who developed a fistula where his colon was rejoined after rectal cancer surgery
What they received
endoscopic manual suturing of the fistula opening (after argon treatment)
Compared with
an earlier attempt to close it with vacuum-assisted closure
Main outcome
whether the fistula opening closed completely
Quality
this is a single patient case report, so it cannot show whether this approach generally works.
Limitations
single case, not a classic anal fistula but a post-surgical anastomotic fistula, no comparison group, short observation before switching to surgery
Taken word for word from the abstract
- n A 54-year-old male underwent a low anterior resection in 2015 for rectal adenocarcinoma.
- population A 54-year-old male underwent a low anterior resection in 2015 for rectal adenocarcinoma.
- intervention we proceeded with continuous manual suturing after argon application
- comparator Vacuum-assisted closure was attempted but was unsuccessful due to technical difficulties and the small size of the cavity.
- primaryOutcome achieving complete closure of the fistulous opening
- result A follow-up colonoscopy showed persistence of the fistulous orifice with suture material, although radiologically there was a clear decrease in the abscess.
- result a planned surgical intervention was decided
- followUp after one month of hospitalization with a stable fistula but no definitive resolution
Rev Esp Enferm Dig · PMID 39784726 · Read it on PubMed ↗
Yang et al. 2024
Medium- to long-term outcomes of seton placement for fistula-in-ano in children: the experience of 103 patients from a single institution
Most fistulas healed after seton surgery.Case seriesLow qualityRelated question
103 people23 (6-58) months
97 of 103 patients healed well, 4 healed after further dressing changes and debridement, and 2 needed a second seton procedure for recurrence
Who was studied
children with anal fistula
What they received
seton placement (a surgical thread technique for fistula)
Compared with
no comparison group; all patients received seton placement
Main outcome
whether the fistula healed after treatment
Quality
This is a retrospective case series of one surgical technique with no comparison group, so it cannot show whether non-surgical healing is possible.
Limitations
Retrospective, single-institution, no control or non-surgical comparison group, and the population is children rather than a general population of fistula patients.
Taken word for word from the abstract
- population The clinical data of children with anal fistula treated by seton placement admitted from January 2017 to September 2022 were retrospectively analyzed.
- intervention evaluate the efficacy of seton placement for anal fistula in children
- comparator The clinical data of children with anal fistula treated by seton placement admitted from January 2017 to September 2022 were retrospectively analyzed.
- primaryOutcome The aim of this study was to evaluate the efficacy of seton placement for anal fistula in children.
- result A total of 97 patients experienced good healing, four patients experienced poor healing and healed after dressing change and debridement, and two patients with multiple fistulas who experienced recurrence underwent a second seton placement.
- n Among the 103 patients, 75 with a single fistula and 20 with a double fistula were treated by primary seton placement.
- followUp The median follow-up time of these patients was 23 (6-58) months
Pediatr Surg Int · PMID 39709324 · Read it on PubMed ↗
Neville et al. 2025
Non-operative Versus Operative Management of Perianal Abscess in Infants: A 10-year Retrospective Study at Two Centres in the United Kingdom
No difference in fistula ratesRetrospectiveLow qualityRelated question
116 people3 (IQR 2-6) months
Abscess recurrence was higher after non-operative treatment, but the rate of later fistula was not significantly different between the two groups
Who was studied
infants aged 12 months or younger with a perianal abscess
What they received
non-operative treatment (antibiotics and/or aspiration under local anaesthetic)
Compared with
operative treatment (incision and drainage under general anaesthesia)
Main outcome
recurrence of the abscess and later development of anal fistula
Quality
It is a retrospective chart review from two centres without randomisation, so differences between groups could reflect which infants were chosen for each treatment rather than the treatment itself.
Limitations
Retrospective design, no randomisation, short median follow-up of 3 months, and treatment choice was based on surgeon preference rather than a standard protocol.
Taken word for word from the abstract
- population infants aged ≤12 months presenting with PA to two paediatric surgery centres in the United Kingdom
- intervention non-operative treatments, such as antibiotics and/or aspiration under local anaesthetic
- comparator incision and drainage under general anaesthesia
- primaryOutcome Recurrence occurred in 49/116 (42 %)
- n 116 infants were identified
- result Recurrence occurred in 49/116 (42 %) at a median time of 1 (IQR 0-3) month and was significantly higher in the non-operative compared to the operative group (39/73 [53 %] versus 10/43 [23 %], p = 0.001)
- result Subsequent FIA rates were not significantly different (23/73 [32 %] versus 8/43 [19 %], p = 0.129)
- followUp Median follow-up was 3 (IQR 2-6) months
J Pediatr Surg · PMID 39693822 · Read it on PubMed ↗
Yin et al. 2023
Natural course of perianal abscess in infants: a real-world study
Most infant abscesses healed without surgery.RetrospectiveLow qualityRelated question
153 people5.3 years (range 3-8.2 years)
90.8% were cured without surgery, 7.2% eventually needed surgery, and 2% developed an anal fistula
Who was studied
infants with perianal abscess treated without surgery
What they received
conservative (non-surgical) treatment of perianal abscess
Compared with
surgical treatment
Main outcome
cure without surgery, and development of fistula or recurrent abscess
Quality
This was a retrospective, single-center study where parents chose to avoid surgery, so there is no random comparison and results may not apply to all patients.
Limitations
Retrospective design, single center, treatment chosen by parental refusal of surgery rather than randomization, and the study is about perianal abscess rather than established anal fistula.
Taken word for word from the abstract
- population infants with PA who were treated conservatively (due to the parents' refusal of surgery), for more than 2 months between 2014 and 2020
- intervention conservative treatment
- comparator 11 underwent surgery
- primaryOutcome the rate of fistula formation, abscess recurrence, and new-onset abscess
- result Overall, 139 patients (90.8%) were cured conservatively without surgery, and 11 (7.2%) underwent surgical management. In addition, 3 (2.0%) patients developed fistula-in-ano (under observation).
- n 153 patients (149 boys and 4 girls) were identified.
Sci Rep · PMID 37891236 · Read it on PubMed ↗
Strassmann et al. 2023
Gracilis Muscle Interposition: A Valuable Tool for the Treatment of Failed Repair of Post-partum Rectovaginal Fistulas-A Single-Center Experience
Muscle flap surgery closed recurrent fistulas.Case seriesVery low qualityRelated question
6 people2023
4 of 6 patients healed after the muscle flap surgery; the other 2 healed after one more small procedure, giving 100% eventual success
Who was studied
women with rectovaginal fistulas from childbirth injury that had already failed earlier repairs
What they received
gracilis muscle interposition surgery (a muscle flap placed to close the fistula)
Compared with
no comparison group; outcomes compared with patients' own prior failed procedures
Main outcome
whether the fistula leakage was gone after the temporary stoma was reversed
Quality
This is a tiny retrospective series of only 6 patients with no comparison group, so it can't reliably show whether fistulas heal without surgery.
Limitations
Very small sample, single center, retrospective, no control group, and all patients underwent surgery (with fecal diversion) rather than being observed for non-surgical healing.
Taken word for word from the abstract
- population patients who underwent GMI for post-partum RVF
- intervention gracilis muscle interposition (GMI) for post-partum RVF
- comparator All patients had at least 1 previously failed procedure [median: 3 (1-7)] including endorectal advancement flap, fistulotomy, vaginoplasty, mesh interposition, and sphincteroplasty.
- primaryOutcome Success was defined as absence of leakage from the repair site after stoma reversal.
- result Success was achieved in 4/6 (66.7%) patients; 2 underwent further procedures (1 fistulotomy and 1 rectal flap advancement) for a final 100% success rate as all ileostomies were reversed.
- n Six of 119 patients who underwent GMI did so for recurrent post-partum RVF.
Am Surg · PMID 37216694 · Read it on PubMed ↗
Lin et al. 2023
The Optimal Primary Treatment for Pediatric Perianal Abscess and Anal Fistula: A Systemic Review and Meta-Analysis
Surgery lowers recurrence more than conservative care.Meta-analysisLow qualityRelated question
2,507 people2023
surgery was better at preventing recurrence than conservative treatment or drainage alone
Who was studied
children under 18 with perianal abscess or anal fistula (without Crohn's disease or malignancy)
What they received
conservative treatment or drainage (non-surgical initial management)
Compared with
surgery as initial treatment
Main outcome
recurrence after initial treatment
Quality
No randomized trials were found, only retrospective and small case-series data were pooled.
Limitations
No randomized controlled trials identified; studies were retrospective cohorts or small case series; subgroup analysis of specific approaches could not be performed due to lack of information.
Taken word for word from the abstract
- n Thirty-one studies involving 2507 pediatric patients met the inclusion criteria.
- population patient age of <18 years
- intervention Conservative treatment and drainage revealed no difference
- comparator Compared with incision/drainage, surgery can prevent recurrence remarkably
- primaryOutcome Meta-analyses for recurrence after initial management were performed with a random-effects model.
- result Compared with incision/drainage, surgery can prevent recurrence remarkably (OR 4.360, 95% CI: 1.761-10.792, p = 0.001).
- limitations Strong recommendations cannot be made due to the lack of prospective or randomized controlled studies.
J Pediatr Surg · PMID 36894443 · Read it on PubMed ↗
Kang et al. 2022
Intermediate-Term Evaluation of Initial Non-Surgical Management of Pediatric Perianal Abscess and Fistula-In-Ano
No surgery, similar healing outcomes.RetrospectiveLow qualityRelated question
457 people2022
no significant difference between non-surgical and surgical groups in recurrence, fistula formation or healing, but the non-surgical group had fewer hospital admissions and procedures
Who was studied
children with a first-time perianal abscess or anal fistula
What they received
non-surgical management (no surgery)
Compared with
surgical incision and/or drainage
Main outcome
abscess coming back, fistula forming, and how long the wound took to heal
Quality
this was a retrospective chart review without randomization, so differences between groups could be due to selection rather than treatment.
Limitations
Retrospective design, pediatric population only, and abscess and fistula patients analyzed together rather than fistula alone.
Taken word for word from the abstract
- n A total of 457 patients managed for first-time PA and/or FIA were eligible for the current study.
- population A study of pediatric patients with first-time PA and/or FIA was conducted retrospectively
- intervention 169 (50.9%) patients received non-surgical intervention
- comparator compare the intermediate-term outcomes of non-surgical management with those of surgical incision and/or drainage
- primaryOutcome The clinical outcomes, including PA recurrence, FIA formation, and wound healing time, were compared between the surgical and non-surgical management groups.
- result no difference was noted between the two groups in terms of PA recurrence and/or FIA development rates and revisits for additional treatment
- result non-surgical intervention exhibited promising outcomes for most cases of first-time PA/FIA, with fewer hospital admissions and surgical procedures and similar recurrence and fistula formation incidences
Surg Infect (Larchmt) · PMID 35647894 · Read it on PubMed ↗
Banasiewicz et al. 2021
Statement of the polish expert group on the current practice and prospects for the treatment of complex perianal fistulas in Crohn's disease. Update 2021
Surgery plus drugs works best, Crohn's fistulas.GuidelineVery low qualityRelated question
size not given2021
combining surgery and medication worked better than either approach by itself
Who was studied
people with perianal fistulas caused by Crohn's disease
What they received
combination of surgical and drug (medication) therapy
Compared with
surgical treatment alone or drug treatment alone
Main outcome
how effective fistula treatment is
Quality
This is an expert group statement summarizing opinions and practice recommendations, not a study with original patient data or measured outcomes.
Limitations
No study design, patient numbers, or outcome data are given; this is a consensus/expert opinion document specifically about Crohn's-related fistulas, not fistulas in general.
Taken word for word from the abstract
- population Perianal fistulas in Crohn's disease (CD) are a major problem.
- intervention The combination of surgical and pharmacological therapy is more effective than surgical or pharmacological therapy alone.
- comparator is more effective than surgical or pharmacological therapy alone
- result The combination of surgical and pharmacological therapy is more effective than surgical or pharmacological therapy alone.
- primaryOutcome Treatment of fistulas might be challenging and requires cooperation between the colorectal surgeon and the gastroenterologist.
Pol Przegl Chir · PMID 34515655 · Read it on PubMed ↗
Khan et al. 2021
Perianal magnetic resonance imaging findings and their potential impact on outcome in children with perianal fistulizing Crohn disease
Complex fistulas more likely need surgery.RetrospectiveLow qualityRelated question
99 people5.5 years
Fistula branching and older age at MRI were linked to a higher chance of later needing surgery
Who was studied
children with Crohn disease and perianal fistula who had pelvic MRI
What they received
MRI-identified fistula features (branching, supralevator extension, sphincter damage) and age
Compared with
children without these MRI features
Main outcome
whether the child later needed surgery for the fistula
Quality
This is a retrospective review of one hospital's records, not a trial testing treatments, so it cannot show whether fistulas heal without surgery.
Limitations
Retrospective design, single cohort, only MR-identified features and age analyzed, no comparison of treatment types or healing without surgery reported.
Taken word for word from the abstract
- n Ninety-nine children with Crohn disease underwent pelvic MR.
- population children with Crohn disease and perianal fistula who underwent pelvic MR
- intervention Radiologists reviewed pelvic MR exams and identified Park classification and additional anatomical features of perianal fistulas, including fistula branching, horseshoe ramifications, abscess, inflammatory mass, supralevator extension, anal sphincter damage, proctitis and posterior anal space involvement.
- comparator 69 children had no surgical interventions prior to baseline MRI
- primaryOutcome features associated with subsequent surgical intervention
- result A multivariable model identified only fistula branching (HR: 2.31; 95% CI: 1.28-4.15; P=0.005) and age (HR: 5.18; CI: 1.57-17.14; P=0.007) as independent predictors of subsequent surgery.
- followUp subsequent median clinical follow-up of 5.5 years
Pediatr Radiol · PMID 34490496 · Read it on PubMed ↗
Arroyo-Martinez et al. 2020
Urgent care practice in anorectal abscess. Still a pending task
Fistula linked to abscess recurrence.RetrospectiveLow qualityRelated question
190 people2020
having an associated anal fistula was the only factor linked to abscess coming back
Who was studied
patients treated for anorectal abscess in an emergency department
What they received
emergency treatment of anorectal abscess (mostly simple drainage, with or without antibiotics)
Compared with
different treatment approaches used in the emergency department (varying use of antibiotics, referral practices)
Main outcome
risk factors for abscess recurrence
Quality
this is a retrospective, single-center study without a control group comparing surgery versus no surgery for fistula healing, so it can't directly answer whether fistulas heal without surgery.
Limitations
retrospective design, single center, no direct comparison of surgical versus non-surgical fistula treatment, and the abstract notes 'great clinical variability' in care with no clear impact on outcomes
Taken word for word from the abstract
- n corresponding to 190 patients
- population Patients who underwent surgery for AA between 2016 and 2017 were included in the study
- intervention The most frequent treatment in the emergency department (ED) was simple drainage (75.8%)
- comparator There is great clinical variability regarding the taking of cultures, prescription of antibiotics, and referral criteria to a specialized coloproctology outpatient department
- primaryOutcome The recurrence risk factors were also evaluated
- result The only risk factor associated with recurrence was the presence of an associated anal fistula
Cir Cir · PMID 33254180 · Read it on PubMed ↗
Oteo Manjavacas et al. 2020
Endoscopic treatment of recto-vesical fistula after radical prostatectomy. Our findings in 2 patients
Fistula closed without major surgery.Case seriesVery low qualityRelated question
2 people36 months
both patients' fistulas healed and stayed closed over follow-up
Who was studied
patients who developed a recto-vesical fistula after prostate removal surgery
What they received
minimally invasive endoscopic closure of the fistula plus prolonged bladder catheter use
Compared with
no comparison group
Main outcome
whether the fistula healed, confirmed by imaging
Quality
Only two patients were treated with no comparison group, so it can't show how often this works compared to surgery.
Limitations
Very small number of patients (2), no control group, and this is a different type of fistula (bladder-to-rectum after prostate surgery) rather than an anal fistula.
Taken word for word from the abstract
- population The recto-vesical fistula (FRV) that follows a radical prostatectomy is an unusual complication
- intervention The conservative treatment consisted in the use of transrectal endoscopic approach and minimally invasive techniques for the closure of the fistulous orifice and a prolonged use of the bladder catheter.
- comparator We present 2 cases with an early diagnosis of postoperative FRV resolved with minimally invasive treatment
- primaryOutcome confirming the resolution of the recto-vesical fistula by cystography and CT
- result The two patients were followed up at least 36 months, confirming the resolution of the recto-vesical fistula by cystography and CT.
- n We present 2 cases with an early diagnosis of postoperative FRV resolved with minimally invasive treatment
Arch Esp Urol · PMID 33144540 · Read it on PubMed ↗
Stokes et al. 2020
Management of perianal abscesses in infants without general anaesthesia: a systematic review of the literature
Most infant abscesses healed without surgery.Systematic reviewLow qualityRelated question
1,049 people2020
75.3% healed completely without further treatment, 23.2% had recurrence or progressed to a fistula, and only 5.6% eventually needed general anaesthesia
Who was studied
infants under 24 months old with perianal abscesses
What they received
treating the abscess without general anaesthesia (antibiotics, baths, needle draining, or local-anaesthetic drainage)
Compared with
historical approach of general anaesthesia for drainage and fistula exploration
Main outcome
how many infants ended up needing general anaesthesia after being treated without it first
Quality
The evidence comes mostly from retrospective case series with no randomized trials, so it's a weak basis for conclusions.
Limitations
No randomized controlled trials; mostly retrospective cohort studies; abstract notes 'lack of well-designed prospective studies'.
Taken word for word from the abstract
- population infants less than 24 months old
- intervention management of perianal abscesses without GA
- comparator Historically, general anaesthesia (GA) has been used to facilitate incision and drainage, with or without exploration for a fistula-in-ano (FIA).
- primaryOutcome The primary outcome was the number of patients requiring GA following initial management without GA.
- result A total of 790 (75.3%) healed primarily without further intervention. A total of 243 (23.2%) were documented to have a recurrence or progression to FIA.
- result Of these, 59 (5.6%) were documented to subsequently require a general anaesthetic.
- n Nine studies, involving 1049 infants less than 24 months old met inclusion criteria.
- qualityWhy Despite the lack of well-designed prospective studies, existing evidence supports management of perianal abscesses without initial GA in infants
Pediatr Surg Int · PMID 32785778 · Read it on PubMed ↗
Boenicke et al. 2020
Efficacy of conservative treatment of perianal abscesses in children and predictors for therapeutic failure
Surgery often needed; conservative care rarely curative.RetrospectiveLow qualityRelated question
113 people2020
only 14 of 113 children were cured by conservative treatment alone, while most eventually needed surgery
Who was studied
children younger than 14 years old with a perianal abscess
What they received
conservative (non-surgical) treatment of the abscess
Compared with
surgery for the abscess
Main outcome
whether the abscess resolved permanently without needing surgery
Quality
it is a retrospective review of children's records without randomization, so differences in who got surgery versus conservative care could bias the findings.
Limitations
Retrospective design, no randomization between treatment groups, and the condition studied is perianal abscess rather than an established anal fistula.
Taken word for word from the abstract
- population All cases of children younger than 14 years of age with perianal abscesses between 2001-2016 were evaluated.
- n Of the 113 enrolled patients, 64 underwent subsequent surgery for advanced disease (primary surgery group).
- intervention Conservative treatment was initiated in 49 patients (primary conservative group)
- comparator 64 underwent subsequent surgery for advanced disease (primary surgery group)
- primaryOutcome To evaluate the efficiency of conservative treatment of perianal abscess in children and identify parameters that predict therapy failure.
- result Overall, conservative treatment alone was effective in only 14 of 113 patients.
Clin Exp Pediatr · PMID 32408417 · Read it on PubMed ↗
Bałaż et al. 2020
Perianal abscess and fistula-in-ano in children - evaluation of treatment efficacy. Is it possible to avoid recurrence?
Surgery prevented recurrence; drainage alone did not.RetrospectiveLow qualityRelated question
24 people2020
patients who had the fistula tract surgically opened (fistulotomy) had no recurrence or incontinence, while those treated with drainage alone elsewhere had more severe disease and needed further surgery
Who was studied
infants and children with perianal abscess caused by anal fistula
What they received
surgical fistulotomy (cutting open the fistula tract)
Compared with
non-surgical care such as sitz baths, antibiotics, or incision and drainage without fixing the fistula
Main outcome
recurrence of abscess and fecal incontinence
Quality
This was a small retrospective study of only 24 children without a randomized comparison group, so it can't reliably prove one treatment is better.
Limitations
Retrospective design, small sample size (24 patients), no randomization, and the comparison group's prior treatments were done at other hospitals with unclear standardization.
Taken word for word from the abstract
- population The retrospective study included 24 infants with perianal abscess treated at our center between 2013 and 2015.
- intervention Fistula-in-ano was intraoperatively identified in all patients (100%) and fistulotomy was performed.
- comparator Minimally invasive approach (sitz baths, antibiotic therapy, puncture or incision and drainage of the abscess) appears tempting due to its simplicity and lack of need for general anesthesia, but it is associated with a high recurrence rate.
- primaryOutcome No fecal incontinence or recurrence of perianal abscess were observed in any of our patients.
- result Fistulotomy and fistulectomy, which are slightly more invasive procedures, significantly reduce the recurrence rate of fistulain- ano and perianal abscess.
- n The retrospective study included 24 infants with perianal abscess treated at our center between 2013 and 2015.
Pol Przegl Chir · PMID 32312918 · Read it on PubMed ↗
Bislenghi et al. 2020
Surgical management of acquired rectourethral fistula: a retrospective analysis of 52 consecutive patients
Mostly needed surgery to heal.RetrospectiveLow qualityRelated question
52 people10.5 (0.5-16.8) years
3 of 52 patients healed with conservative management alone; the remaining 49 needed surgery, with cumulative closure reaching 96% after up to three operations
Who was studied
men with rectourethral fistula (an abnormal connection between the rectum and urinary tract), mostly after surgery or radiation
What they received
various surgical repair procedures tailored to fistula complexity
Compared with
conservative (non-surgical) management
Main outcome
fistula closure and need for permanent urinary/bowel diversion (stoma)
Quality
This is a retrospective case series from one center without a control group comparing surgery to no surgery, so it cannot reliably show whether surgery was truly necessary.
Limitations
Retrospective design, no control group, and this is about rectourethral fistula (bladder-to-rectum), not anal fistula, so findings may not directly apply.
Taken word for word from the abstract
- n 52 patients were identified (100% males)
- population Acquired rectourethral fistula (RUF) is an uncommon complication mostly resulting from surgery or radiation.
- intervention The surgical strategy was tailored to complexity of RUF, presence of sepsis, history of radiation and residual urinary/fecal functionality.
- comparator Three patients had RUF closure after conservative management.
- primaryOutcome Outcomes measured were RUF closure and permanent fecal/urinary diversion.
- result Three patients had RUF closure after conservative management. The remaining 49 patients had a total of 76 procedures. The cumulative closure rate after the first, second and third attempt was 55.1%, 85.7% and 95.9%, respectively.
- followUp Median follow-up was 10.5 (0.5-16.8) years.
Tech Coloproctol · PMID 32301002 · Read it on PubMed ↗
Rosenbaum et al. 2020
[Fistula surgery]
Different fistula type, not answered hereNarrative reviewLow qualityRelated question
size not given2020
Surgery closes fistulas at a high rate; conservative catheter drainage can work if caught early, but it covers a different fistula type (vesicovaginal/urorectal), not anal fistula
Who was studied
People with vesicovaginal or urorectal fistulas (not anal fistula)
What they received
Temporary catheter drainage as conservative treatment
Compared with
Surgical repair of the fistula
Main outcome
Whether the fistula closes permanently
Quality
This is a general narrative review about vesicovaginal and urorectal fistulas, not anal fistula, so it does not directly answer the question and gives no study numbers.
Limitations
No patient numbers, study design, or statistics are given; it discusses a different fistula population than anal fistula.
Taken word for word from the abstract
- population Vesicovaginal fistulas are a rare problem in the western world but are frequent occurrences in developing countries.
- population The incidence and complexity of urorectal fistulas increase with the number of cumulative sequences of prostate cancer treatment.
- intervention conservative treatment with a temporary catheter drainage can be tried, depending on the underlying cause
- comparator The surgical treatment of both vesicovaginal and urorectal fistulas is associated with high permanent fistula closure rates
- primaryOutcome associated with high permanent fistula closure rates
- result for both entities if the fistula is discovered early enough, conservative treatment with a temporary catheter drainage can be tried, depending on the underlying cause
- result for both conditions fistula repair in irradiated patients shows a much lower success rate
Urologe A · PMID 32236687 · Read it on PubMed ↗
Popov et al. 2019
[Conservative management of rectourethral fistula: modern treatment]
Most healed without surgery.Case seriesLow qualityRelated question
5 people24 month
4 of 5 patients (80%) had their fistula heal without surgery
Who was studied
patients who developed a recto-urethral fistula after prostate cancer surgery
What they received
conservative (non-surgical) management: bowel rest, antibiotics, special diet, bladder drainage
Compared with
no comparison group; outcomes tracked within same patients
Main outcome
whether the fistula healed without surgery
Quality
Very small, uncontrolled case series with only five patients, so the result could easily be due to chance or selection of mild cases.
Limitations
Very small sample, no control group, excluded more complicated cases (fecaluria, prior radiotherapy), and this fistula type (recto-urethral, from prostate surgery) differs from an anal fistula.
Taken word for word from the abstract
- population Postoperatively RUF developed in 7 patients (0.8%) in average in 10 days after surgery.
- population Rectal injury and recto-urethral fistula (RUF) formation are severe complications after surgical treatment of prostate cancer
- intervention Conservative management include: 1)bowel rest 2)broad-spectrum antibiotics after urine culture 3) fully absorbable diet (combination of parenteral and enteral nutrition) 4) bladder drainage (urethral catheter or suprapubic tube).
- comparator The remaining 4 patients had spontaneous healing of the fistula and normal cystourethrogram.
- primaryOutcome Overall RUF closure using nonsurgical treatment was successful in 4 of 5 cases (80%).
- result Overall RUF closure using nonsurgical treatment was successful in 4 of 5 cases (80%).
- n Five cases were uncomplicated presented with pneumaturia, dysuria or urine per rectum.
- followUp With the median follow up of 24 month after RUF treatment all 4patients had no fistula signs and they were fully continent.
Urologiia · PMID 32003166 · Read it on PubMed ↗
Palumbo et al. 2019
The use of Argentum-Quartz® solution in primary or recurrent perianal fistulas: first experience on three cases
Non-surgical fistula healing reported.Case seriesVery low quality
size not given2019
preliminary data suggest fistula healing is achievable without surgery, sparing the sphincter
Who was studied
patients with primary or recurrent perianal fistulas, some with Crohn's disease or ulcerative colitis
What they received
Argentum-Quartz solution applied non-surgically
Compared with
none described
Main outcome
healing of perianal fistula
Quality
Only a few cases with no comparison group, so it cannot reliably show whether the treatment works.
Limitations
Described as preliminary data from a small case series with no control group.
Taken word for word from the abstract
- population Primary perianal fistulous pathology represents a painful condition often noticeable in patients affected by Crohn's disease or Ulcerative colitis.
- intervention Argentum-Quartz® as valid non-surgical therapeutic treatment
- primaryOutcome a more comfortable perianal fistula healing
- result our preliminary data allow us to consider Argentum Quartz® ideally employable for treatment of perianal fistulas associated or not with IBDs, representing a reliable sphincter-sparing solution.
- comparator non-surgical therapeutic treatment
Clin Ter · PMID 31612187 · Read it on PubMed ↗
Samuk et al. 2019
Perianal abscess in infants: Amenable to conservative treatment in selected cases
Most infants avoided surgery; one fistula healed alone.RetrospectiveLow qualityRelated question
19 peoplemean, 22.4 months
surgical intervention was prevented in 13/17 patients (76.4%) available for follow up
Who was studied
infants under 24 months with perianal abscess
What they received
conservative treatment (antibiotics with drainage only if needed)
Compared with
surgical drainage/fistulotomy
Main outcome
whether surgery was ultimately needed
Quality
This was a small, retrospective study of hand-picked ('selected') cases with two patients lost to follow-up, so it can't reliably prove conservative care works for everyone.
Limitations
Retrospective design, small sample, only 'selected cases' included, two patients lost to follow up, and the study is about perianal abscess rather than fistula specifically.
Taken word for word from the abstract
- n Data of 19 patients aged <24 months treated conservatively for perianal abscess at a tertiary hospital in 2014-2018 were retrospectively reviewed.
- population Data of 19 patients aged <24 months treated conservatively for perianal abscess
- intervention evaluate the outcomes of conservative approach in selected cases of perianal abscesses in infants
- comparator the most frequent approach is drainage with/without fistulotomy
- primaryOutcome Three patients (15.7%) ultimately required surgical drainage
- result surgical intervention was prevented in 13/17 patients (76.4%) available for follow up
Pediatr Int · PMID 31469939 · Read it on PubMed ↗
Maternini et al. 2020
Non cross-linked equine collagen (Salvecoll-E gel) for treatment of complex ano-rectal fistula
Most fistulas healed with gel treatment.Prospective cohortLow qualityRelated question
70 people12 months
78.5% of patients had a healed fistula, 21.5% had recurrence by 12 months
Who was studied
adults with complex anal fistula
What they received
collagen gel (Salvecoll-E) injected into the fistula tract after seton removal and minor surgical preparation
Compared with
none (single-arm study, no comparison group)
Main outcome
fistula healing at 12 months
Quality
This was a small, single-arm study without a comparison group, so it can't show the gel works better than surgery or no treatment.
Limitations
No control group, open-label single-arm design, and treatment combined gel injection with prior surgical steps (seton placement, debridement, mucosal suture).
Taken word for word from the abstract
- n the efficacy of Salvecoll-E gel for anal fistula repair in 70 patients
- population Fistula-in-ano is one of the most commonly presenting anorectal diseases. Sphincter sparing treatment options should be considered in patients with complex fistulas.
- intervention Salvecoll-E was injected through the external opening into the fistula track, the external opening it has been opened.
- comparator The multicentric trial study was a prospective, single-arm observational clinical study
- primaryOutcome Twelve months after surgery, 55 patients demonstrated a clinically healed fistula (78,5%), 15 patients have a recurrence (21,5%).
- result 55 patients demonstrated a clinically healed fistula (78,5%), 15 patients have a recurrence (21,5%).
Asian J Surg · PMID 31320233 · Read it on PubMed ↗
Banasiewicz et al. 2019
Statement of the expert group on the current practice and prospects for the treatment of complex perirectal fistulas in the course of Crohn's disease
Combined surgery plus drugs works better alone.Narrative reviewVery low quality
size not given2019
combined surgical and drug treatment worked better than either approach alone
Who was studied
people with perirectal fistulas caused by Crohn's disease
What they received
combined surgical and drug treatment (including anti-TNF drugs like infliximab, adalimumab, certolizumab)
Compared with
surgery alone or drug treatment alone
Main outcome
how effectively the fistulas were treated
Quality
this is an expert group's opinion statement summarizing practice, not a controlled study with original data or a systematic review of evidence.
Limitations
No original patient data, no study methodology, numbers, or comparative statistics are given; it is a narrative expert opinion piece.
Taken word for word from the abstract
- population Perirectal fistulas in the course of Crohn's disease (CD) constitute an important problem in this group of patients.
- intervention The combination of surgical and pharmacological treatment has higher efficacy compared to surgical treatment or pharmacotherapy alone.
- comparator surgical treatment or pharmacotherapy alone
- primaryOutcome higher efficacy
- result The combination of surgical and pharmacological treatment has higher efficacy compared to surgical treatment or pharmacotherapy alone.
Pol Przegl Chir · PMID 30919811 · Read it on PubMed ↗
Steinhart et al. 2019
Clinical Practice Guideline for the Medical Management of Perianal Fistulizing Crohn's Disease: The Toronto Consensus
Drugs can help; surgery sometimes still needed.GuidelineVery low qualityRelated question
size not given2019
Medical drugs can bring on remission and keep it, but surgery may still be needed if drugs don't work well enough
Who was studied
people with anal fistulas caused by Crohn's disease
What they received
medical treatments such as antibiotics, anti-TNF drugs, and immune-suppressing drugs
Compared with
surgical treatment of the fistula
Main outcome
whether the fistula heals or goes into remission
Quality
The guideline itself says the evidence behind these recommendations is generally very low quality with few good trials.
Limitations
Evidence quality was rated very low overall, with a scarcity of good randomized controlled trials, so most recommendations are only conditional suggestions.
Taken word for word from the abstract
- population patients with perianal fistulizing CD
- intervention Antitumor necrosis factor (anti-TNF) therapy was recommended to induce symptomatic response
- comparator surgical therapy may provide effective fistula healing for some patients
- primaryOutcome continued use was suggested to achieve and maintain complete remission
- result When there has been an inadequate symptomatic response to medical management strategies, surgical therapy may provide effective fistula healing for some patients.
- qualityWhy The quality of evidence for treatment of fistulizing CD was generally of very low quality
- limitations because of the scarcity of good randomized controlled trials (RCTs), these consensus statements generally provide conditional suggestions (5 of 7 statements)
Inflamm Bowel Dis · PMID 30099529 · Read it on PubMed ↗
Dryden et al. 2017
Comparison of Stromal Vascular Fraction with or Without a Novel Bioscaffold to Fibrin Glue in a Porcine Model of Mechanically Induced Anorectal Fistula
Cell therapy with scaffold healed fistulas better in pigsAnimal studyVery low qualityRelated question
17 people4 weeks
All 6 fistulas treated with SVF plus scaffold healed, compared with 4 of 6 treated with SVF alone and none of 5 treated with fibrin glue
Who was studied
Pigs with surgically created anal (anorectal) fistulas
What they received
Stromal vascular fraction (SVF) cells injected alone or delivered via a bioabsorbable scaffold
Compared with
Fibrin glue injection into the fistula
Main outcome
Whether the fistula tract healed (visual and histologic healing)
Quality
This is a small animal (pig) experiment, not a human study, so it cannot show how human fistulas heal with or without surgery.
Limitations
Small number of animals per group, mechanically created (not Crohn's-related) fistulas in pigs, and no human data.
Taken word for word from the abstract
- population ARFs were mechanically created and matured by setons.
- intervention The cells were labeled with a membrane stain for later identification, then injected into the fistula or implanted through scaffold.
- comparator Fistulas not treated with cells were injected with fibrin glue.
- primaryOutcome Animals were monitored visually for healing at weeks 2 and 4, then euthanized to evaluate fistulas for histologic healing.
- result All fistulas (6/6) treated with SVF + scaffolds healed by week 2, compared with only 4/6 with just SVF and 0/5 treated with fibrin glue.
- n 6/6) treated with SVF + scaffolds healed by week 2, compared with only 4/6 with just SVF and 0/5 treated with fibrin glue
- followUp monitored visually for healing at weeks 2 and 4
Inflamm Bowel Dis · PMID 28945635 · Read it on PubMed ↗
Serra-Aracil et al. 2018
The Place of Transanal Endoscopic Surgery in the Treatment of Rectourethral Fistula
Few healed without surgery.Prospective cohortVery low qualityRelated question
10 people4-6 months
only 2 of 10 fistulas healed without surgery; of those who had transanal surgical repair, only 25% succeeded and most recurred, requiring further surgery
Who was studied
men with rectourethral fistula after prostate cancer surgery
What they received
conservative treatment (urinary/fecal diversion) or transanal endoscopic surgery to repair the fistula
Compared with
surgical repair vs conservative management, compared across patients
Main outcome
whether the fistula healed
Quality
This was a very small study of only 10 patients, not randomized, and focused on a different and more complex type of fistula.
Limitations
Very small sample size, observational design without a control group, and the fistula type (rectourethral, after prostate cancer treatment) differs from typical anal fistula.
Taken word for word from the abstract
- population All patients were diagnosed with RUF following management of prostate cancer.
- intervention If the fistula persisted, it was treated by TEO or TEM, with or without biological mesh interposition.
- comparator Conservative treatment was administered in the form of urinary and fecal diversion with cystotomy and terminal colostomy, to achieve total urinary and fecal exclusion.
- primaryOutcome To assess the role of transanal endoscopic operation (TEO) or transanal endoscopic microsurgery (TEM) in rectourethral fistulas (RUF).
- result In 1 patient (1 of 10), the fistula healed with bladder catheterization alone. In another patient (1 of 9), it resolved after total urinary and fecal exclusion.
- result a success rate of 25%
- n Ten patients were diagnosed with RUF.
- followUp the others had healed at follow-up visits after 4-6 months
Urology · PMID 28916253 · Read it on PubMed ↗
Gong et al. 2018
Treatment of First-Time Perianal Abscess in Childhood, Balance Recurrence and Fistula Formation Rate with Medical Intervention
Fewer fistulas with non-surgical abscess care.RetrospectiveLow qualityRelated question
697 people395 days
conservative treatment had a lower recurrence/fistula rate than incision and drainage (12.7% vs 24.6%, p<0.001)
Who was studied
children with first-time perianal abscess
What they received
conservative (non-surgical) medical treatment
Compared with
incision and drainage surgery
Main outcome
rate of recurrence and/or later fistula formation
Quality
It is a retrospective study comparing treatments without randomization, so other differences between groups could explain the result.
Limitations
Retrospective design without randomization; abstract does not address healing of an already-formed fistula, only prevention of fistula after abscess.
Taken word for word from the abstract
- n A total of 697 patients with first-time perianal abscess were included in this study.
- population A total of 697 patients with first-time perianal abscess were included in this study.
- intervention 355 (50.9%) patients who received conservative treatment had 12.7% (45/355) RF rate
- comparator which is less than that of abscesses treated with ID (24.6%, 72/297; p < 0.001)
- primaryOutcome a wide range of recurrences and/or development of fistula-in-ano (RF) rates have been reported
- result which is less than that of abscesses treated with ID (24.6%, 72/297; p < 0.001)
- followUp The median follow-up period was 395 days (range: 120-760 days).
Eur J Pediatr Surg · PMID 28564707 · Read it on PubMed ↗
Milito et al. 2017
Surgical Treatment of Rectovaginal Fistula in Crohn's Disease: A Tertiary Center Experience
Most healed after surgery, none without it.RetrospectiveLow qualityRelated question
43 people18 months
81% of patients healed after surgery, 19% failed, with a median time to success of six months
Who was studied
women with rectovaginal fistula caused by Crohn's disease
What they received
surgical repair of the fistula using various techniques (seton, flap procedures, mesh, muscle flap)
Compared with
different surgical techniques compared to each other (no non-surgical group)
Main outcome
whether the fistula healed after surgery
Quality
This is a retrospective, uncontrolled case series from one center with no comparison to non-surgical treatment, so it can't show whether fistulas heal without surgery.
Limitations
Retrospective design, single surgeon/center, no control group, and focuses on rectovaginal fistula in Crohn's disease rather than general anal fistula or non-surgical management.
Taken word for word from the abstract
- population Rectovaginal fistula (RVF) is a disastrous complication of Crohn's disease (CD)
- n All 43 patients that underwent surgery for RVF were affected by Crohn's disease.
- intervention Four different surgical approaches were performed: drainage and seton, rectal advacenment flap (RAF), vaginal advancement flap (VAF), transperineal approach using porcine dermal matrix (PDM), and martius flap (MF).
- comparator No demographic of disease-related factors were found to influence healing.
- primaryOutcome The failure group rate was 19% in contrast with the healing rate group that was 81%.
- result The median time to success was six months (range 2-11). None of the patients were lost during the 18 months of follow-up. The failure group rate was 19% in contrast with the healing rate group that was 81%.
Surg Technol Int · PMID 28395390 · Read it on PubMed ↗
Kouchi et al. 2017
Efficacy of an anal fistula plug for fistulas-in-Ano in children
Fistula plug healed most pediatric fistulas.Case seriesVery low qualityRelated question
8 people2017
8 of 11 fistulas (72.7%) healed successfully; 3 recurred and required surgery (fistulectomy)
Who was studied
children with anal fistulas that didn't heal despite long-term conservative treatment
What they received
anal fistula plug (Surgisis Anal Fistula Plug) placed in the fistula tract
Compared with
none (single-arm treatment study)
Main outcome
whether the fistula closed and healed
Quality
This was a small, uncontrolled case series of only 8 children, so it can't reliably show whether the plug works better than no treatment or surgery.
Limitations
No control group, very small number of patients, and the plug is not an approved device in the study's country, which may affect wider applicability.
Taken word for word from the abstract
- population We classified refractory fistulas as those treated for 6months or longer and remaining unhealed, even after 1year of age, despite continued conservative treatment.
- intervention The plug was used in 11 refractory fistulas in 8 children.
- comparator The plug was used in 11 refractory fistulas in 8 children.
- primaryOutcome This study was designed to analyze the efficacy of the plug for closure of refractory fistulas in children.
- result Eight of 11 fistulas (72.7%) were successfully treated. Three fistulas recurred, and fistulectomies were performed.
- n The plug was used in 11 refractory fistulas in 8 children.
J Pediatr Surg · PMID 28209416 · Read it on PubMed ↗
Emile et al. 2016
A systematic review of the management of anal fistula in infants
Many infants healed without surgery.Systematic reviewLow qualityRelated question
490 people2016
About 20% of infants were treated conservatively first, and 73% of them had complete resolution without surgery
Who was studied
infants younger than 2 years old with anal fistula
What they received
conservative (non-surgical) treatment
Compared with
surgical treatment (fistulotomy or fistulectomy)
Main outcome
complete resolution of the fistula and recurrence rate
Quality
This review pooled mostly small, non-randomized case series without a formal quality assessment, so the conservative-treatment findings are based on limited, less rigorous data.
Limitations
The review combines heterogeneous studies, and only a minority of infants received conservative treatment, limiting how confidently results generalize.
Taken word for word from the abstract
- population FIA in infants less than 2 years old
- n total of 490 infants
- intervention Around 20 % of patients with FIA underwent conservative treatment initially
- comparator Surgery was performed on 86 % of the infants.
- primaryOutcome Variables analyzed comprised patient characteristics, type of FIA, methods of treatment, recurrence, and postoperative complications.
- result 73 % of them achieved complete resolution
Tech Coloproctol · PMID 27663698 · Read it on PubMed ↗
Kaimakliotis et al. 2016
A Systematic Review Assessing Medical Treatment for Rectovaginal and Enterovesical Fistulae in Crohn's Disease
Some fistulas closed without surgery.Systematic reviewLow qualityRelated question
181 people2016
fistulas closed completely in some patients but many had no response, with better closure rates for enterovesical than rectovaginal fistulas
Who was studied
people with Crohn's disease who have rectovaginal or enterovesical fistulas
What they received
medical therapy (including anti-TNF drugs), alone or combined with surgery
Compared with
no formal comparison group; rates compared across different treatment approaches (medical alone, anti-TNF, medical plus surgery)
Main outcome
whether the fistula fully closed, partly closed, or did not respond
Quality
the review combined many small, low-quality studies without a control group, so the findings are not very reliable.
Limitations
abstract states studies were small and of low quality, with no consensus on management and a call for larger, better studies
Taken word for word from the abstract
- population patients with Crohn's disease
- intervention medical management of rectovaginal and enterovesical fistulae in Crohn's disease
- comparator The response to a combination of medical and surgical therapy in 43 rectovaginal fistulae was: 44.2% complete response, 20.9% partial response, and 34.9% no response.
- primaryOutcome to assess their response to treatment
- result The overall response rates of rectovaginal fistulae to medical therapy were: 38.3% complete response (fistula closure), 22.3% partial response, and 39.4% no response. For enterovesical fistulae the response rates to medical therapy were: 65.9% complete response, 20.5% partial response, and 13.6% no response.
- n Twenty-three studies were identified, reporting on 137 rectovaginal and 44 enterovesical fistulae.
- limitations given the small size and low quality of the published studies, it is still difficult to draw conclusions regarding treatment
J Clin Gastroenterol · PMID 27466166 · Read it on PubMed ↗
Lo et al. 2016
Rectovaginal fistula: Twenty years of rectovaginal repair
Most fistulas needed surgery to heal.RetrospectiveLow qualityRelated question
397 people12 months
56 patients (14.1%) had conservative treatment and 341 (85.9%) had surgery; overall 344 patients (86.7%) had improved outcome at 12 months, and the authors concluded surgery is the preferred option while medical treatment should be used only for small fistulas or unsuitable surgical candidates
Who was studied
women diagnosed with rectovaginal fistula at a Taiwan hospital
What they received
conservative (non-surgical) treatment
Compared with
surgical repair (simple repair or reconstruction)
Main outcome
improved outcome at 12 months after treatment
Quality
This is a retrospective review of rectovaginal (not anal) fistulas that does not directly compare healing rates between conservative and surgical treatment, so it only weakly and indirectly informs the question.
Limitations
Retrospective design, no direct statistical comparison of outcomes between conservative and surgical groups, and the population studied (rectovaginal fistula) differs from anal fistula.
Taken word for word from the abstract
- population All female patients with International Classification of Diseases RVF were included.
- n A total of 397 patients were included in the study.
- intervention Fifty-six patients (14.1%) had conservative treatment
- comparator 341 patients (85.9%) underwent surgical intervention
- primaryOutcome clinical outcome at 12 months postoperatively
- result Three hundred and forty-four patients (86.7%) had improved outcome at 12-month follow up.
- result Surgery is the preferred option, while medical treatment should be used only for small rectovaginal fistulas or for patients not suitable for surgery and anesthesia.
J Obstet Gynaecol Res · PMID 27354199 · Read it on PubMed ↗
Cordova et al. 2016
Recurrent Pediatric Perianal Swelling
Recommends combining surgery and medicine.Narrative reviewVery low qualityRelated question
size not given2016
guidelines recommend combining surgery with medication, not medication alone
Who was studied
children with Crohn's disease and perianal complications
What they received
medicines that calm inflammation (immunomodulators and biologics) plus surgery
Compared with
not clearly compared, general treatment approach described
Main outcome
treating perianal Crohn's disease including fistulas and abscesses
Quality
this is a general review and case report discussion, not a study testing whether fistulas heal without surgery.
Limitations
abstract does not report a specific study, data, or outcomes comparing surgery versus no surgery; it is a general review of pediatric perianal Crohn's disease.
Taken word for word from the abstract
- population Pediatric inflammatory bowel disease is a chronic gastrointestinal disease consisting of Crohn's disease (CD) and ulcerative colitis (UC).
- intervention controlling intestinal inflammation with the use of immunomodulators (6-mercaptopurine and methotrexate) and biologics (infliximab and adalimumab)
- comparator Current treatment strategies are focused on the surgical drainage of abscesses and the closure of fistulous tracts
- primaryOutcome treatment of perianal CD
- result Current guidelines by the American Gastroenterology Association and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition recommend a combination of surgical intervention and medical management for the treatment of perianal CD.
Pediatr Ann · PMID 26878185 · Read it on PubMed ↗
Park et al. 2016
Allogeneic adipose-derived stem cells for the treatment of perianal fistula in Crohn's disease: a pilot clinical trial
Some fistulas healed without surgery here.Case seriesVery low qualityRelated question
6 people8 weeks, with additional follow-up to 6 months and up to month 8 for responders
3 of 6 patients had complete fistula closure (two by 4-6 months, one by 8 weeks); no serious treatment-related side effects
Who was studied
People with Crohn's disease who have a fistula near the anus
What they received
Injection of donor (allogeneic) fat-derived stem cells into the fistula, at two different doses
Compared with
No comparison group; the two dose groups were compared to each other
Main outcome
Complete closure of the fistula by 8 weeks after injection
Quality
This was a tiny, uncontrolled pilot study in only 6 patients with no comparison group, so it cannot show whether the treatment itself caused the healing.
Limitations
Very small sample size, no control group, open-label design, and dose-escalation pilot structure limit conclusions about effectiveness.
Taken word for word from the abstract
- n The first three patients (group 1) were administered 1 × 10(7) cells/ml
- population perianal fistula in Crohn's disease
- intervention allogeneic adipose-derived stem cells for the treatment of perianal fistula in Crohn's disease
- comparator The first three patients (group 1) were administered 1 × 10(7) cells/ml based on the size of the fistula tract. Four weeks later, after which time this dose had been confirmed to be safe, the next three patients (group 2) were administered 3 × 10(7) cells/ml.
- primaryOutcome The end-point was complete closure at 8 weeks after the injection.
- result Two patients in group 1 achieved complete closure of the fistula at month 4 and month 6, and one patient in group 2 achieved complete closure at 8 weeks.
- result There were no adverse events of Grade 3 or 4 severity and no adverse events related to the treatment with allogeneic adipose-derived stem cells.
Colorectal Dis · PMID 26603576 · Read it on PubMed ↗
Lewis et al. 2013
Surgical treatment of anorectal crohn disease
Surgery often less effective in Crohn's.Narrative reviewLow quality
size not given2013
Surgical repair methods all show reduced effectiveness in Crohn disease patients, and in active disease only drainage and seton placement are advised, not definitive repair
Who was studied
people with Crohn disease who have anal/perineal fistulas
What they received
surgical repair options for fistula-in-ano (fistulotomy, fibrin glue, anal fistula plug, flap, LIFT)
Compared with
non-surgical management (drainage, seton, medical therapy) or no treatment
Main outcome
successful fistula healing/closure
Quality
This is a narrative review discussing treatment options without original data, patient numbers, or controlled comparisons.
Limitations
No original study data, no patient numbers, no control group, purely descriptive review of surgical options.
Taken word for word from the abstract
- population Crohn disease involves the perineum and rectum in approximately one-third of patients.
- intervention Several options for definitive surgical repair are discussed, including fistulotomy, fibrin glue, anal fistula plug, endorectal advancement flap, and ligation of intersphincteric fistula tract procedure.
- comparator In the presence of active proctitis or perineal disease, no surgical therapy other than drainage of abscesses and loose seton placement is recommended
- primaryOutcome Fistula-in-ano and perineal sepsis are the most frequent manifestation seen on presentation.
- result All suffer from decreased efficacy in patients with Crohn disease.
Clin Colon Rectal Surg · PMID 24436656 · Read it on PubMed ↗
Dewint et al. 2014
Adalimumab combined with ciprofloxacin is superior to adalimumab monotherapy in perianal fistula closure in Crohn's disease: a randomised, double-blind, placebo controlled trial (ADAFI)
Fistulas healed with drug therapy, not surgery.Randomised trialModerate qualityRelated question
76 people24 weeks
71% responded to combination therapy vs 47% to adalimumab alone at week 12, but no difference remained at week 24
Who was studied
adults with Crohn's disease and active perianal fistulas
What they received
adalimumab plus ciprofloxacin
Compared with
adalimumab plus placebo
Main outcome
50% reduction in draining fistulas at 12 weeks
Quality
It was a well-designed randomized, double-blind, placebo-controlled trial, but it was fairly small and the early benefit did not last after stopping the antibiotic.
Limitations
Small sample size (76 patients); benefit of combination therapy was not maintained after antibiotic discontinuation; population limited to Crohn's disease fistulas rather than general anal fistula population.
Taken word for word from the abstract
- population 76 CD patients with active perianal fistulising disease were enrolled
- intervention patients received 40 mg every other week together with ciprofloxacin 500 mg
- comparator adalimumab plus placebo
- primaryOutcome Primary endpoint (clinical response) was defined as 50% reduction of fistulas from baseline to week 12.
- result Clinical response was observed in 71% of patients treated with adalimumab plus ciprofloxacin and in 47% treated with adalimumab plus placebo (p=0.047).
- result At week 24, no difference in clinical response between the two treatment groups was observed (p=0.22).
- n In total, 76 CD patients with active perianal fistulising disease were enrolled.
- followUp Follow-up was 24 weeks.
Gut · PMID 23525574 · Read it on PubMed ↗
Osman et al. 2013
Repair of fistulae in-ano in children using image guided Histoacryl injection after failure of conservative treatment
Fistula healed without surgery in most children.Case seriesLow qualityRelated question
30 people18 months
16 of 17 patients (94%) treated with the glue injection had their fistula close, though 2 had it come back and needed repeat injection
Who was studied
children and infants with perianal fistula who had already tried conservative treatment
What they received
injection of tissue glue (N Butyl Cyanoacrylate/Histoacryl) into the fistula tract under imaging guidance
Compared with
no formal comparison group; some patients instead had standard surgery
Main outcome
whether the fistula closed up (healed)
Quality
This was a small, uncontrolled group of patients without randomization or a comparison group, so it can't firmly prove the glue caused the healing.
Limitations
Small sample size, no control group, no randomization, and the successful group was a subset of a larger mixed population.
Taken word for word from the abstract
- n 30 patients who presented with a perianal fistula (25 males and 5 females) were studied
- population infants and children
- intervention injection of adhesive material through the fistula under fluoroscopic guidance and general anesthesia after failure of medical management
- comparator 7 patients were subjected to surgical intervention
- primaryOutcome successful closure of their fistula
- result 16 (94%) of 17 patients have had successful closure of their fistula, and one of them healed from a second injection
J Pediatr Surg · PMID 23480921 · Read it on PubMed ↗
Morcos et al. 2013
Contemporary management of perianal conditions in febrile neutropenic patients
Fistula outcomes not specifically reported.RetrospectiveVery low qualityRelated question
933 people2013
only 4 of 26 septic perianal conditions were fistulas, and the abstract does not separately report how these fistulas were treated or whether they healed; overall, surgery was mainly reserved for collections and most patients without a collection were managed conservatively
Who was studied
adult patients with fever and low white blood cell counts (from chemotherapy) who had perianal problems
What they received
conservative (non-surgical) management of perianal conditions
Compared with
surgical drainage or debridement
Main outcome
management approach and outcome (including death) of septic perianal conditions
Quality
this is a small retrospective chart review in cancer patients with low white blood cell counts, with only 4 fistula cases and no fistula-specific outcomes reported, so it cannot reliably answer whether fistulas heal without surgery.
Limitations
Retrospective review; very small number of fistula patients (4); no separate outcome data for fistulas; population is febrile neutropenic (cancer/chemotherapy) patients, not the general population with anal fistula.
Taken word for word from the abstract
- n 933 patients
- population adult febrile neutropenic patients
- intervention Most patients who had no collection had conservative management.
- comparator Surgery was done in 13 patients to drain a collection and in 2 patients to debride necrotic tissue.
- primaryOutcome the risk factors, management options and outcome of septic perianal conditions
- result abscess (12 patients), fistula (4), inflammation (9) and necrotizing fasciitis (1)
- result Surgical drainage should be reserved to conditions where there is a collection; otherwise patients should be managed conservatively but with close monitoring.
Eur J Surg Oncol · PMID 23347777 · Read it on PubMed ↗
Beaulieu et al. 2013
Fistula-in-ano: when to cut, tie, plug, or sew
Non-surgical care often fails, surgery usually needed.Narrative reviewVery low qualityRelated question
size not given2013
the abstract states that medical management often fails with high recurrence, leading patients to need surgical care, but gives no specific outcome data
Who was studied
people with anal fistula (fistula-in-ano)
What they received
different surgical techniques for treating anal fistula
Compared with
non-surgical (conservative) management of anal fistula
Main outcome
healing of the wound and ability to control bowel movements after treatment
Quality
This is a surgeon's practice overview and opinion piece, not a study with measured outcomes or a control group.
Limitations
No original data, no defined outcomes, numbers, or comparison group; describes general surgical practice and techniques rather than a study.
Taken word for word from the abstract
- population managing patients with fistula-in-ano
- intervention surgical approaches available to ensure the highest possible postoperative continence and wound healing
- comparator failed conservative management
- primaryOutcome postoperative continence and wound healing
- result high rates of recurrence with medical management commonly bring these patients under the care of the colorectal surgeon after variable periods of failed conservative management
J Gastrointest Surg · PMID 23315048 · Read it on PubMed ↗
Topazio et al. 2012
Conservative treatment of a recto-urethral fistula due to salvage HIFU for local recurrence of prostate cancer, 5 years after radical prostatectomy and external beam radiotherapy
Healed without surgery.Case seriesVery low qualityRelated question
1 people24 months
no recurrence of the fistula was found 24 months after treatment
Who was studied
68-year-old man with a recto-urethral fistula after prostate cancer treatment (HIFU, prior prostatectomy and radiotherapy)
What they received
conservative treatment with an indwelling Foley catheter, no surgery
Compared with
no intestinal diversion surgery was performed
Main outcome
whether the fistula healed or recurred over follow-up
Quality
this is a single patient case report, so it cannot show what usually happens or rule out chance.
Limitations
single case, fistula caused by HIFU/radiotherapy for prostate cancer rather than typical anal fistula disease
Taken word for word from the abstract
- n a 68-year-old patient
- population We report the case of a recto-urethral fistula in a 68-year-old patient, who previously had undergone radical prostatectomy and EBRT for prostate cancer
- intervention The fistula was treated conservatively by an indwelling Foley catheter, without the creation of an intestinal diversion.
- comparator without the creation of an intestinal diversion
- primaryOutcome reassessed periodically by means of retrograde urethrograms
- result To date, 24 months after this episode, no evidence of recurrence of the fistula has been found.
BMJ Case Rep · PMID 23144340 · Read it on PubMed ↗
Tomasello et al. 2012
Argentum-quarz solution in the treatment of anorectal fistulas: is it possible a conservative approach?
No clinical data, just a hypothesis.Narrative reviewVery low qualityRelated question
size not given2012
The paper proposes and discusses a theoretical mechanism by which silver and quartz could help heal fistulas, without presenting clinical outcome data
Who was studied
Patients with anorectal fistulas, often linked to Crohn's disease, Ulcerative Colitis, or Indeterminate Colitis
What they received
Argentum-quarz (silver and quartz) solution applied to the fistula as a conservative treatment
Compared with
Standard surgical treatment, and fibrin glue as an alternative conservative approach
Main outcome
Potential healing of anorectal fistulas without surgery
Quality
This is a theoretical/hypothesis paper with no patient data or clinical results reported.
Limitations
The abstract describes only a proposed hypothesis and discussion of a therapeutic mechanism; it reports no actual patients, trial, or measured outcomes.
Taken word for word from the abstract
- population Patients suffering from chronic intestinal diseases (Crohn's disease, Ulcerative Colitis, Indeterminate Colitis) are prone to the development of pyogenic complications.
- intervention the therapeutic potential of silver and quarz in the conservative treatment of anorectal fistulas
- comparator prospective studies have proposed an alternative conservative therapeutic approach based on application of fibrin glue in the healing of patients with fistulas-in-ano
- primaryOutcome we suggest and discuss the therapeutic potential of silver and quarz in the conservative treatment of anorectal fistulas pointing out their role in modulating particular steps of the pathogenetic process
- result In this paper we suggest and discuss the therapeutic potential of silver and quarz in the conservative treatment of anorectal fistulas pointing out their role in modulating particular steps of the pathogenetic process which characterizes this pathological condition.
Med Hypotheses · PMID 22867866 · Read it on PubMed ↗
Borda Mederos et al. 2011
[Experience with a biological plug for biological in complex anal fistula]
Plug healed most fistulas, no incontinence.Case seriesLow quality
46 people29.8 months
the plug closed the fistula successfully in about 74% of patients over a median follow-up of nearly 2.5 years, with no incontinence reported
Who was studied
patients with complex anorectal fistula, most with previous surgery
What they received
biological plug (Surgisis AFP) placed in the fistula tract without surgery
Compared with
no concurrent comparison group; historical comparison with other fistula techniques
Main outcome
closure/success of the fistula without recurrence
Quality
it is a retrospective review of one treatment group without a comparison arm, so it cannot prove the plug works better than surgery.
Limitations
retrospective design, no control group, single-center case review
Taken word for word from the abstract
- n We retrospectively reviewed the results of 46 patients with complex anorectal fistula treated with the biological plug over a period of 4 years.
- population 41 were recurrent fistulas (89.1%) and 5 high transsphincteric fistulas (10.8%)
- intervention The biologic plug Surgisis® AFP it's being used since 2006 and produces the closure of the fistula in approximately 12 weeks, without surgery
- comparator Use of anal fistula plug Surgisis® AFP is a new alternative with acceptable results in terms of recurrence comparable to other techniques, but with no incontinence.
- primaryOutcome The anal fistula plug was successful in 73.9% of cases with a median follow-up 29.8 months.
- result The anal fistula plug was successful in 73.9% of cases with a median follow-up 29.8 months.
Rev Gastroenterol Peru · PMID 22476123 · Read it on PubMed ↗
Abcarian 2011
Anorectal infection: abscess-fistula
Surgery always needed, says review.Narrative reviewLow quality
size not given2011
the abstract states fistula treatment is surgical in all cases, with conservative (non-sphincter-cutting) procedures resulting in more recurrence or persistence requiring repeat operations
Who was studied
adults with anorectal abscess or fistula
What they received
surgical treatment of anal fistula (various techniques)
Compared with
different surgical approaches to each other (sphincter-cutting vs conservative)
Main outcome
cure of fistula versus fecal incontinence and recurrence
Quality
this is a narrative review of general treatment approaches without original patient data or controlled comparison, so it cannot reliably establish whether fistulas heal without surgery.
Limitations
no original data, no specific numbers of patients, no controlled comparison, author opinion-based review
Taken word for word from the abstract
- population Anorectal abscess and fistula are among the most common diseases encountered in adults.
- intervention The treatment of a fistula, although surgical in all cases, is more complex due to the possibility of fecal incontinence as a result of sphincterotomy.
- comparator trading radical surgery for conservative (nonsphincter cutting) procedures such as a draining seton, fibrin sealant, anal fistula plug, endorectal advancement flap, dermal island flap, anoplasty, and LIFT (ligation of intersphincteric fistula tract) procedure all result in more recurrence/persistence requiring repeated operations in many cases
- primaryOutcome So even though the aim of a surgical procedure is to cure a fistula, conservative management short of major sphincterotomy is warranted to preserve fecal incontinence.
- result The treatment of a fistula, although surgical in all cases, is more complex due to the possibility of fecal incontinence as a result of sphincterotomy.
Clin Colon Rectal Surg · PMID 22379401 · Read it on PubMed ↗
Sileri et al. 2011
Surgery for fistula-in-ano in a specialist colorectal unit: a critical appraisal
Unclear resultProspective cohortLow qualityRelated question
247 people6 months
61% of patients had their fistula tract eradicated with surgery, and only 2.4% had incontinence
Who was studied
adults with anal fistulas (mostly from infection, some from Crohn's disease or ulcerative colitis)
What they received
surgical treatment (fistulotomy, fistulectomy, seton placement, or rectal flap)
Compared with
different surgical techniques compared to each other, not to no surgery
Main outcome
whether the fistula healed and whether incontinence occurred
Quality
this is a single-center case series of surgical patients with no non-surgical comparison group, so it cannot show whether fistulas heal without surgery.
Limitations
No randomization, no comparison to non-surgical management, and the abstract itself calls for high-quality randomized trials.
Taken word for word from the abstract
- n 247 patients presenting with anal fistulas were treated
- population 247 patients presenting with anal fistulas were treated at the University Hospital Tor Vergata
- intervention Patients were treated using 4 operative approaches: fistulotomy, fistulectomy, seton placement and rectal advancement flap.
- comparator Data analyzed included: age, gender, type of fistula, operative intervention, healing rate, postoperative complications, reinterventions and recurrence.
- primaryOutcome The main treatment successfully eradicated the primary fistula tract in 151/247 patients (61%)
- result The main treatment successfully eradicated the primary fistula tract in 151/247 patients (61%). Three cases of major incontinence (1.3%) were detected during the follow-up period
- followUp minimum follow-up period was 6 months (mean 40, range 6-74 months)
BMC Gastroenterol · PMID 22070555 · Read it on PubMed ↗
Afşarlar et al. 2011
Perianal abscess and fistula-in-ano in children: clinical characteristic, management and outcome
Few fistulas healed without surgery.RetrospectiveLow qualityRelated question
158 people10.6 ± 8.6 months
9 of 52 fistulas healed without surgery; the other 43 needed surgical treatment
Who was studied
children with perianal abscess or anal fistula
What they received
non-surgical management (drainage, local care, with or without antibiotics)
Compared with
surgical treatment (fistulotomy or fistulectomy)
Main outcome
whether the anal fistula healed on its own or needed surgery
Quality
This was a retrospective chart review without a control group, so the comparison between spontaneous healing and surgery isn't a fair test.
Limitations
Retrospective design, no randomization or control group, and the study is in children, who may differ from adults with anal fistula.
Taken word for word from the abstract
- n A total of 158 children (146 males, 12 females) treated for perianal abscess and fistula-in-ano
- population children with perianal abscess and fistula-in-ano
- intervention local care for the spontaneously (S/D) drained abscess (26.5%) with or without antibiotic therapy
- comparator 43 of the remaining needed surgical intervention (fistulotomy/fistulectomy)
- primaryOutcome development of fistula-in-ano
- result While the 9 of the overall 52 fistula-in-ano (22 initial, 30 after abscess treatment) were resolved spontaneously, 43 of the remaining needed surgical intervention (fistulotomy/fistulectomy).
- followUp The mean follow-up period was 10.6 ± 8.6 months.
Pediatr Surg Int · PMID 21785979 · Read it on PubMed ↗
Netsch et al. 2011
Rectourethral fistula after high-intensity focused ultrasound therapy for prostate cancer and its surgical management
Fistulas did not heal without surgery.RetrospectiveVery low qualityRelated question
8 people50.45 ± 25.07 months
Conservative treatment failed in all patients, and all required major surgery to close the fistula
Who was studied
men who developed a fistula between the rectum and urethra after high-intensity focused ultrasound treatment for prostate cancer
What they received
conservative (non-surgical) treatment of the fistula
Compared with
major surgical repair (e.g., flap interposition, bowel resection)
Main outcome
whether the fistula healed without surgery
Quality
This is a small, retrospective series of a rare complication in a different type of fistula (urinary-rectal, not anal), with no comparison group.
Limitations
Retrospective design, very small number of cases, single condition-specific fistula type, no control group, possible selection bias in reporting treatment failures.
Taken word for word from the abstract
- population 8 cases of rectourethral fistula (RUF) in patients treated with high-intensity focused ultrasound (HIFU) for either localized or locally recurrent prostate cancer (PCa)
- intervention Conservative treatment failed in all patients.
- comparator 4 underwent radical prostatectomy, with an omentum flap interposition, 3 received a gracilis interposition flap
- primaryOutcome Conservative treatment failed in all patients.
- result Spontaneous closure of RUF will not occur, requiring major abdominal surgery for definitive repair.
- n A total of 8 patients (2.2%) developed RUF.
- followUp The mean follow-up was 50.45 ± 25.07 months (range 25 to 84).
Urology · PMID 21215427 · Read it on PubMed ↗
Chang et al. 2010
Clinical characteristics and treatment of perianal abscess and fistula-in-ano in infants
Most infants healed without surgery.RetrospectiveLow qualityRelated question
112 people23.7 ± 11.7 months
86.6% of infants were cured with conservative treatment, while 10.7% needed surgery and none of those recurred after surgery
Who was studied
infant boys with perianal abscess and fistula-in-ano
What they received
conservative (non-surgical) treatment
Compared with
surgical fistulectomy
Main outcome
cure of the perianal abscess/fistula
Quality
It's a single-surgeon retrospective review without a comparison group, so it can't firmly prove conservative treatment is better than surgery.
Limitations
Retrospective design, single surgeon, no control group, and study limited to infants rather than the general population with anal fistula.
Taken word for word from the abstract
- population 112 infants who were treated for perianal abscess and fistula-in-ano
- intervention conservative treatment
- comparator underwent fistulectomy
- primaryOutcome cured by conservative treatment
- result Ninety-seven patients (86.6%) were cured by conservative treatment with a mean duration of 5.2 ± 3.9 months from the onset of the disease to the cure.
- result Twelve patients (10.7%) underwent fistulectomy at a mean age of 15.0 ± 5.1 months. None of the patients had recurrences after operation
- n 112 infants who were treated for perianal abscess and fistula-in-ano
- followUp mean follow-up period of 23.7 ± 11.7 months
J Pediatr Surg · PMID 20850628 · Read it on PubMed ↗
Ezer et al. 2010
Perianal abscess and fistula-in-ano in children: aetiology, management and outcome
Mostly needed surgery to heal.Case seriesLow quality
39 people2010
most children who had non-surgical treatment for abscess went on to develop a fistula, and most fistulas needed surgery, with some recurring even after a first operation
Who was studied
children with perianal abscess and/or fistula-in-ano
What they received
non-surgical treatment (incision and drainage with or without antibiotics, or antibiotics alone)
Compared with
surgical treatment (fistulotomy or fistulectomy)
Main outcome
whether the fistula healed or needed surgery, and recurrence after treatment
Quality
this is a small, retrospective review of patients from one hospital with no comparison group, so it can't reliably show whether non-surgical care works.
Limitations
retrospective design, small sample, some patients lost to follow-up, no control group comparing treatments directly
Taken word for word from the abstract
- n The study consisted of 39 patients (36 boys)
- population perianal abscess and/or fistula-in-ano in children
- intervention local care with antibiotic therapy was given to four patients
- comparator underwent surgical treatment either through a fistulotomy or through a fistulectomy
- primaryOutcome treatment modality and recurrences were recorded
- result Of 20 patients with perianal abscess, 17 developed fistula-in-ano and three healed.
- result Thirty-three patients with fistula-in-ano underwent surgical treatment either through a fistulotomy or through a fistulectomy.
- result Five (15.1%) patients who experienced recurrent fistula-in-ano underwent fistulotomy were completely cured after the second operation.
J Paediatr Child Health · PMID 20105258 · Read it on PubMed ↗
Thomas et al. 2010
Incidence, clinical symptoms and management of rectourethral fistulas after radical prostatectomy
Some fistulas healed without surgery.RetrospectiveVery low qualityRelated question
13 people59 months
all 3 patients treated conservatively healed without surgery; with colostomy 3 of 9 closed spontaneously while 6 of 9 needed surgery (all successful); surgery without colostomy failed in the 1 patient who had it
Who was studied
men who developed a rectourethral fistula after surgery to remove the prostate for cancer
What they received
conservative (non-surgical) management of the fistula, sometimes with a temporary colostomy
Compared with
colostomy with or without surgical closure, or immediate surgical closure without colostomy
Main outcome
whether the fistula closed (healed)
Quality
This is a small retrospective review of only 13 patients from one hospital, so the numbers are too small to draw firm conclusions.
Limitations
Very small sample, retrospective design, single institution, and the fistulas studied are a specific type (rectourethral) caused by prostate surgery rather than typical anal fistulas.
Taken word for word from the abstract
- n Rectourethral fistulas developed in 13 of 2,447 patients (0.53%) after radical prostatectomy.
- population Patients in whom postoperative rectourethral fistulas developed were identified.
- intervention group 1-conservative treatment
- comparator group 2-colostomy with or without surgical closure and group 3-immediate surgical closure without colostomy
- primaryOutcome the fistula closed spontaneously with conservative treatment
- result In all patients in group 1 (3) the fistula closed spontaneously with conservative treatment. None of these patients had fecaluria. In group 2 of the 9 patients 3 (33%) experienced spontaneous fistula closure after temporary colostomy and transurethral catheterization. In this group 6 patients (67%) required additional surgical fistula closure, which was successful in all. Surgical fistula closure (1) without colostomy in presence of fecaluria failed (group 3).
- followUp Median followup was 59 months.
J Urol · PMID 20018317 · Read it on PubMed ↗
Lozynskyy 2009
Treatment algorithms in the case of perianal complications of Crohn's disease
Almost all fistulas were operated on.Case seriesVery low qualityRelated question
52 people2009
51 of 52 patients with fistulas were operated on; the abstract does not report healing without surgery for fistula patients
Who was studied
patients with Crohn's disease who had perianal fistula
What they received
surgical treatment of perianal fistula
Compared with
conservative (non-surgical) treatment, as used for fissures in the same cohort
Main outcome
whether the fistula healed or needed surgery
Quality
This is a retrospective case series without a comparison group, so it cannot show whether fistulas heal without surgery.
Limitations
No control group, no statistical comparison, and the population is specifically Crohn's disease patients rather than general anal fistula patients.
Taken word for word from the abstract
- n 144 had perianal complications (60 fissure, 52 fistula, 61 perianal abscess)
- population 310 patients with Crohn's disease (CD) have been treated in our clinic of which 144 had perianal complications (60 fissure, 52 fistula, 61 perianal abscess)
- intervention 51 patients with fistulas were operated on
- comparator Using conservative treatment for patients with fissure, clinical remission was attained in 45 (75%)
- result 51 patients with fistulas were operated on
- primaryOutcome 51 patients with fistulas were operated on
Dig Dis · PMID 19897976 · Read it on PubMed ↗
de Parades et al. 2010
Seton drainage and fibrin glue injection for complex anal fistulas
Half healed without full surgery.Case seriesLow quality
30 people11.7 months (range, 0.2-33.5 months)
50% of patients were cured at end of follow-up; success was higher with regional anaesthesia than general anaesthesia (68.4% vs 18.2%)
Who was studied
adults with complex anal fistula
What they received
seton drainage for 8 weeks followed by fibrin glue injection
Compared with
none (single-arm, with comparison of regional vs general anaesthesia subgroups)
Main outcome
complete fistula closure without seepage or abscess
Quality
This was a small, single-group study without a comparison treatment, so it can't prove surgery is avoidable, only that some patients healed with this non-surgical approach.
Limitations
No control group, small sample size, and some patients had delayed abscess after initial healing.
Taken word for word from the abstract
- n Thirty consecutive patients with a complex anal fistula underwent glue instillation
- population Thirty consecutive patients with a complex anal fistula underwent glue instillation after an 8 week period of seton drainage.
- intervention Thirty consecutive patients with a complex anal fistula underwent glue instillation after an 8 week period of seton drainage.
- comparator There was, however, a significant difference in success following regional vs general anaesthesia (68.4 vs 18.2% success, P = 0.02).
- primaryOutcome Cure was defined as complete closure of any secondary opening, absence of fistula seepage, and no abscess formation.
- result At the end of follow-up, 15 (50%) patients were considered to have been cured.
- result There was, however, a significant difference in success following regional vs general anaesthesia (68.4 vs 18.2% success, P = 0.02).
- followUp The mean duration of follow-up was 11.7 (range, 0.2-33.5) months.
Colorectal Dis · PMID 19210300 · Read it on PubMed ↗
Schwab et al. 2008
[Urethral fistula due to Crohn's disease: case report of successful conservative management]
Fistula healed without surgery.Case seriesVery low qualityRelated question
1 people2008
complete remission achieved without surgery
Who was studied
a patient with a recto-urethral fistula caused by Crohn's disease
What they received
suprapubic cystostomy plus antibiotics (ciprofloxacin, metronidazole) and immunosuppressive drug (azathioprine)
Compared with
none
Main outcome
complete healing of the fistula
Quality
This is a single patient case report, so it cannot show whether this result would happen in others.
Limitations
Only one patient reported; this fistula was due to Crohn's disease and involved the urethra, not a typical anal fistula.
Taken word for word from the abstract
- population a case of a recto-urethral fistula in Crohn's disease
- intervention suprapubic cystostomy, ciprofloxacin, metronidazole, and azathioprine
- comparator led to complete remission
- primaryOutcome led to complete remission
- result led to complete remission
- n We report a case of a recto-urethral fistula in Crohn's disease.
Urologe A · PMID 18483799 · Read it on PubMed ↗
Angelberger et al. 2008
NOD2/CARD15 gene variants are linked to failure of antibiotic treatment in perianal fistulating Crohn's disease
Antibiotics healed some fistulas, not others.Prospective cohortLow qualityRelated question
52 people2008
13 of 39 patients with the normal gene had complete fistula closure (33.3%), compared with none of the patients carrying the gene variant (0%)
Who was studied
adults with draining perianal fistulas caused by Crohn's disease
What they received
antibiotic therapy (ciprofloxacin or metronidazole)
Compared with
patients with NOD2/CARD15 wild-type gene versus those carrying NOD2/CARD15 variants
Main outcome
complete closure of the fistula (no drainage even with gentle pressure)
Quality
this was a small, non-randomized study with no surgical comparison group, so it can only hint at how genetics affect antibiotic response, not prove antibiotics alone cure fistulas.
Limitations
Small sample size, no control group without antibiotics, specific to Crohn's-related fistulas rather than general anal fistulas, and genotyping subgroup results involved very few variant carriers.
Taken word for word from the abstract
- population Fifty-two patients (median age 36 yr) with draining perianal fistulas
- intervention treated with ciprofloxacin (N = 49) or metronidazole (N = 3) for a median duration of 7 wk
- comparator NOD2/CARD15 wild-type (33.3%) compared with none in patients carrying NOD2/CARD15 variants (0%
- primaryOutcome Complete response was defined as the absence of any draining fistula despite gentle finger compression
- result Complete fistula response was observed in 13 of 39 patients with NOD2/CARD15 wild-type (33.3%) compared with none in patients carrying NOD2/CARD15 variants (0%, P= 0.02)
- n Fifty-two patients (median age 36 yr)
Am J Gastroenterol · PMID 18371140 · Read it on PubMed ↗
Basilico et al. 2006
[Anastomotic fistulas after colorectal resection for carcinoma: incidence and treatment in our recent experience]
Some surgical leaks healed without reoperationRetrospectiveLow qualityRelated question
373 people2006
9 of 25 fistulas (36%) closed with conservative treatment, while 16 (64%) required reoperation
Who was studied
patients with colorectal cancer who had bowel resection with anastomosis
What they received
conservative (non-surgical) treatment of anastomotic leak
Compared with
reoperation for the leak
Main outcome
whether the anastomotic fistula closed
Quality
This is a single-center retrospective review of surgical complications, not a study of anal fistula disease or a controlled comparison.
Limitations
Retrospective, single institution, no control group, and this concerns anastomotic leaks after cancer surgery rather than cryptoglandular anal fistula.
Taken word for word from the abstract
- population 448 patients affected with colorectal cancer were operated on
- n in 373 cases an anastomosis was performed
- intervention the fistulas spontaneously closed with conservative treatment
- comparator in 16 (64%) reoperation was necessary
- primaryOutcome Twenty-five out of 373 anastomotic leaks developed (6.7%)
- result In 9 cases (36%), the fistulas spontaneously closed with conservative treatment, while in 16 (64%) reoperation was necessary.
Minerva Chir · PMID 17159744 · Read it on PubMed ↗
Rosen et al. 2000
The nonoperative management of fistula-in-ano
Fistulas healed without surgery.Case seriesLow qualityRelated question
18 people37 months
all 14 fistulas healed without surgery over a mean of 6 months
Who was studied
male infants with perianal abscess or fistula
What they received
watchful waiting without surgery (drainage only if very uncomfortable or febrile)
Compared with
none (no comparison group; historical standard is fistulotomy)
Main outcome
whether the fistula healed without operation
Quality
small, uncontrolled case series in infants without a comparison group, so it cannot prove surgery is unnecessary in general.
Limitations
No control group, small sample, and population limited to male infants, not adults or older children.
Taken word for word from the abstract
- n A conservative approach to perianal abscess and fistula was used prospectively in 18 male infants.
- population infants with perianal fistula
- intervention Abscesses were to be drained only if the baby was very uncomfortable or febrile. Once a fistula developed the authors continued observation until the fistula healed.
- comparator Fistulotomy is the accepted treatment for infants with perianal fistula.
- primaryOutcome Once a fistula developed the authors continued observation until the fistula healed.
- result All fistulas healed without operation.
- followUp Mean follow-up period was 37 months.
J Pediatr Surg · PMID 10873039 · Read it on PubMed ↗
Peitz et al. 1999
[Conservative therapy of fistulas of the anorectal area in Crohn disease]
Drugs support surgery, don't replace it.Narrative reviewVery low qualityRelated question
size not given1999
Abstract describes treatment strategy rather than a measured outcome; drug therapy is used alongside surgical consultation and to maintain remission after surgery, not as a stand-alone cure.
Who was studied
patients with anorectal fistulas caused by Crohn's disease
What they received
conservative drug therapy (metronidazole, azathioprine, cyclosporine)
Compared with
surgical treatment
Main outcome
achieving remission of fistula disease before or after surgery
Quality
This is a descriptive narrative review with no patient numbers or measured outcomes, so it cannot show whether fistulas actually healed.
Limitations
No data, sample size, or outcome measures are given; it only describes treatment selection principles.
Taken word for word from the abstract
- population The conservative treatment of ano-rectal fistulae in Crohn's disease
- intervention metronidazole is indicated in addition to the standard therapy, an immuno-suppressive treatment with azathrioprine is recommended for the chronic-active course
- intervention intravenous therapy with either cyclosporine ot with high-dose azathropine
- comparator The treatment is initiated only after consultation with the surgeon.
- primaryOutcome intended to induce a pre-surgical remission or to maintain a post-surgical remission
- result For the prophylaxis of a post-surgical recurrence, only salicylates are established.
Zentralbl Chir · PMID 10544475 · Read it on PubMed ↗
Bodzin 1998
Laser ablation of complex perianal fistulas preserves continence and is a rectum-sparing alternative in Crohn's disease patients
Healed fistulas, avoided major surgery.Case seriesVery low quality
7 peoplemore than 1 year
all patients improved; 4 of 4 followed over a year healed completely, continence preserved in all 7, none needed rectal removal, 1 recurrence
Who was studied
Crohn's disease patients with severe, debilitating complex perianal fistula disease
What they received
laser ablation of fistula tracts (with seton placement)
Compared with
none (compared historically to diverting ileostomy or proctectomy)
Main outcome
fistula healing, continence preservation, and avoidance of rectal surgery
Quality
this is a very small, uncontrolled case series of only 7 patients from one surgeon, so it can't reliably show the treatment works better than other options.
Limitations
small sample size, no comparison group, single surgeon/center, some patients still healing at time of report
Taken word for word from the abstract
- n 7 of these patients had laser ablation of severe, debilitating complex PAD (13.7%)
- population Laser ablation is a valuable technique in the management of patients with severe, debilitating complex PAD complicating CD.
- intervention The hand-held CO2 laser was used to unroof all fistulas external to the external sphincter.
- comparator These patients have traditionally been treated by diverting ileostomy or proctectomy with permanent diversion.
- primaryOutcome Continence was preserved in 7 of 7 patients. No patient has required rectal excision.
- result The 4 patients in the group operated more than 1 year before this review have all demonstrated complete healing. The three more recent patients are in various stages of healing. Continence was preserved in 7 of 7 patients. No patient has required rectal excision.
Am Surg · PMID 9655272 · Read it on PubMed ↗
Watanabe et al. 1998
Conservative management of fistula in ano in infants
Most infants healed without surgery.Case seriesLow quality
97 people1st year of life
80% of infants recovered spontaneously within their first year, with only 6 children needing surgery after age 2
Who was studied
infants and children with anal fistula or perianal abscess
What they received
conservative management (no surgery, watchful waiting)
Compared with
natural course without fistula surgery
Main outcome
spontaneous recovery/resolution within the first year of life
Quality
This is a small, non-randomized natural-history study in infants with no comparison group, so it can't fully prove surgery is avoidable.
Limitations
No control group, observational natural-course analysis, population limited to infants under age 2
Taken word for word from the abstract
- n 97 children (male: 90, female: 7)
- population fistula in ano (FIA) and/or perianal abscess (PAA) in 97 children
- intervention recommend conservative management in infants
- comparator Fistulotomy or fistulectomy should be avoided in infants.
- primaryOutcome 80% of the infants recovered spontaneously within their 1st year of life
- result A radical operation was required in only 6 children after 2 years of age.
Pediatr Surg Int · PMID 9553188 · Read it on PubMed ↗
Shafik 1996
Non-surgical repair of rectovaginal fistulae
Non-surgical healing achieved with cautery.Case seriesVery low qualityRelated question
12 peoplemean follow-up 24 months
all fistulae healed without recurrence
Who was studied
women with recurrent rectovaginal fistulas (abnormal connections between rectum and vagina)
What they received
electrocauterization of the fistula tract (a heat-based probe treatment)
Main outcome
whether the fistula healed without recurrence
Quality
This was a very small study of only 12 patients with no comparison group, so it can't reliably show how well this works compared to other treatments.
Limitations
Small sample size, no control group, and the fistulas studied were rectovaginal (between rectum and vagina) rather than anal fistulas.
Taken word for word from the abstract
- population Twelve women with recurrent rectovaginal fistulae (RVF) were treated by electrocauterization (EC).
- intervention treated by electrocauterization (EC)
- n Twelve women with recurrent rectovaginal fistulae (RVF)
- primaryOutcome all fistulae healed without recurrence
- result all fistulae healed without recurrence (mean follow-up 24 months)
- followUp mean follow-up 24 months
Eur J Obstet Gynecol Reprod Biol · PMID 8789744 · Read it on PubMed ↗
Lassen et al. 1996
Conservative management of rectocutaneous fistula following radical perineal prostatectomy
Healed without surgery.Case seriesVery low qualityRelated question
3 people1996
all three fistulas healed without surgery
Who was studied
men who developed a rectal-to-skin fistula after prostate removal surgery
What they received
non-surgical care: wound care, antibiotics, bowel rest, IV nutrition, and bladder drainage
Compared with
usual surgical diversion (colostomy)
Main outcome
whether the fistula healed
Quality
only 3 patients with no comparison group, so it can't reliably show what usually happens.
Limitations
Very small case series (3 patients), no control group, and the fistula type (rectocutaneous after prostate surgery) differs from typical anal fistula.
Taken word for word from the abstract
- n We report 3 cases of rectocutaneous fistula following radical perineal prostatectomy
- population rectocutaneous fistula following radical perineal prostatectomy
- intervention appropriate wound care, antibiotics, bowel rest, parenteral hyperalimentation, and, in the presence of a concomitant urine leak in 1 case, optimal urinary diversion and bed rest
- comparator This has traditionally been managed with diverting colostomy until closure of the fistula is assured
- primaryOutcome All fistulas healed without incident.
- result All fistulas healed without incident.
Urology · PMID 8638376 · Read it on PubMed ↗
Hanauer et al. 1993
Rapid closure of Crohn's disease fistulas with continuous intravenous cyclosporin A
Fistulas closed but often relapsed.Case seriesVery low qualityRelated question
5 people6.2 months
10 of the 12 fistulas completely stopped draining, but several later relapsed
Who was studied
people with Crohn's disease who had fistulas that didn't respond to previous surgery or medical treatment
What they received
continuous intravenous cyclosporin A (then switched to oral)
Compared with
none reported
Main outcome
whether the fistulas stopped draining (closed)
Quality
This was a tiny, uncontrolled study of only 5 patients with no comparison group, so it can't reliably show whether the drug—or surgery avoidance—actually works.
Limitations
No control group, only 5 patients with 12 fistulas of mixed types (only 3 perianal), relapses were common, and one serious side effect (mycotic aneurysm) occurred.
Taken word for word from the abstract
- n We treated five patients with Crohn's disease
- population five patients with Crohn's disease complicated by chronic draining fistulas unresponsive to previous surgery, steroids, antibiotics, total parenteral nutrition, 6-mercaptopurine, or azathioprine
- intervention continuous infusion cyclosporin A (CyA)
- comparator We treated five patients with Crohn's disease complicated by chronic draining fistulas unresponsive to previous surgery, steroids, antibiotics, total parenteral nutrition, 6-mercaptopurine, or azathioprine with continuous infusion cyclosporin A (CyA)
- primaryOutcome Complete resolution of drainage was seen in 10 of the 12 fistulas.
- result Complete resolution of drainage was seen in 10 of the 12 fistulas.
- followUp Therapy was continued for a mean of 6.2 months (range, 1.5-18 months).
Am J Gastroenterol · PMID 8480725 · Read it on PubMed ↗
Nelson et al. 1990
Closure of refractory perineal Crohn's lesion. Integration of hyperbaric oxygen into case management
Wound healed with combined intensive therapy.Case seriesVery low qualityRelated question
1 people1990
the wound completely and permanently closed with combined treatment
Who was studied
patient with severe Crohn's disease perineal wound that wouldn't heal after removal of diseased bowel
What they received
hyperbaric oxygen therapy combined with surgical debridement, reconstruction, and medical management
Compared with
none (single case, prior conventional treatments had failed)
Main outcome
complete healing of the perineal wound
Quality
this is a single patient case report, so it cannot show whether this treatment works in general.
Limitations
only one patient; no comparison group; wound was post-surgical not a typical fistula case.
Taken word for word from the abstract
- n A case is reported
- population extensive perineal Crohn's lesion refractory to conventional medical and surgical management
- intervention a comprehensive program of hyperbaric oxygen (HBO), surgical debridement and reconstruction, and continuing medical management
- comparator refractory to conventional medical and surgical management
- primaryOutcome complete and sustained closure of an extensive perineal Crohn's lesion
- result resulted in complete and sustained closure of an extensive perineal Crohn's lesion refractory to conventional medical and surgical management
Dig Dis Sci · PMID 2253542 · Read it on PubMed ↗
Evins 1989
Nonoperative management of iatrogenic prostatorectal fistula
Fistula healed without surgery.Case seriesVery low qualityRelated question
1 people1989
the fistula healed successfully without surgery using conservative management
Who was studied
a patient with a fistula between the prostate and rectum caused by prior urologic surgery
What they received
nonoperative management with low residue diet, Foley catheter drainage, and antibiotics
Compared with
previous standard treatment of colostomy and suprapubic cystostomy diversion with surgical closure
Main outcome
whether the fistula closed and healed
Quality
this is a single case report with no comparison group, so it cannot show how often this works.
Limitations
only one patient described, and the fistula was caused by prostate surgery rather than being a typical anal fistula
Taken word for word from the abstract
- n This case illustrates that a more conservative nonoperative approach can lead to successful closure of such a fistula in selected cases.
- population Iatrogenic prostatorectal fistula is a rarely seen urologic complication of transurethral resection of the prostate and stricture dilatation with sounds.
- intervention The management of the case described here utilizes low residue dietary supplements, Foley catheter drainage, and broad-spectrum antibiotics to allow the fistula to heal.
- comparator In the past, such cases have been managed with colostomy diversion of the fecal stream and suprapubic cystostomy diversion of the urinary stream and in most cases operative closure of the fistula.
- primaryOutcome successful closure of such a fistula in selected cases
- result This case illustrates that a more conservative nonoperative approach can lead to successful closure of such a fistula in selected cases.
Urology · PMID 2775367 · Read it on PubMed ↗
Misra et al. 1988
A new non-operative approach to fistula in ano
Non-surgical wire method healed most fistulas.Case seriesLow quality
56 people1988
recurrence in only 2 of 56 patients, with no cases of temporary or permanent incontinence
Who was studied
patients with low anal fistulas and high horseshoe anal fistulas
What they received
outpatient technique passing a multi-strand stainless steel wire through the fistula tract
Compared with
none reported
Main outcome
fistula recurrence and incontinence of flatus or faeces
Quality
This is a small case series with no comparison group, so it can't prove the new method works better than other options.
Limitations
No control group, no reported follow-up duration, single case series.
Taken word for word from the abstract
- n has been used in 56 patients with low fistulae as well as high horseshoe anal fistulae
- population 56 patients with low fistulae as well as high horseshoe anal fistulae
- intervention The technique involved passing a multi-strand stainless steel wire through the fistulous tract
- comparator The results of a new out-patient approach to fistula in ano are presented.
- primaryOutcome Recurrence was seen in only 2 patients and none of the patients experienced temporary or permanent incontinence of flatus or faeces.
- result Recurrence was seen in only 2 patients and none of the patients experienced temporary or permanent incontinence of flatus or faeces.
Br J Surg · PMID 3208042 · Read it on PubMed ↗
Sweeney et al. 1988
Anal fissure in Crohn's disease
Most fissures healed without surgery.RetrospectiveLow qualityRelated question
61 people1988
the fissure healed in 42 of 61 patients (69%) with medical treatment, while only 6 required surgery (rectal excision) for unhealed fissure
Who was studied
patients with Crohn's disease who had an anal fissure
What they received
conservative medical treatment of the underlying intestinal disease
Compared with
anal surgery
Main outcome
whether the anal fissure healed
Quality
this is a retrospective chart review of a single hospital's case notes without a control group, so it can show what happened but not prove treatment caused it
Limitations
retrospective case-note review, no control group, outcome tied to treatment of Crohn's disease generally rather than the fissure specifically, and this is anal fissure rather than anal fistula
Taken word for word from the abstract
- population there were 61 patients with this diagnosis and an unhealed anal fissure as the only anal lesion
- intervention the fissure healed in 42 (69 per cent) during medical treatment of the intestinal disease
- comparator anal surgery (required in 9.8 per cent of patients in this series) being reserved for the development of other anal disease
- primaryOutcome Of these 61 patients the fissure healed in 42 (69 per cent) during medical treatment of the intestinal disease
- result Of these 61 patients the fissure healed in 42 (69 per cent) during medical treatment of the intestinal disease.
- n there were 61 patients with this diagnosis and an unhealed anal fissure as the only anal lesion
Br J Surg · PMID 3337953 · Read it on PubMed ↗
Goldstein 1987
Anal fissures and fistulas
Fistulas usually need surgery.Narrative reviewVery low quality
size not given1987
acute fissures often heal with conservative care; fistulas generally need surgical treatment (unroofing of abscess or fistulotomy), with simple incision noted to foster recurrence
Who was studied
people with anal fissures and anal fistulas
What they received
conservative management (for fissures) or unroofing/fistulotomy (for fistulas)
Compared with
simple incision drainage versus unroofing; conservative management versus sphincterotomy
Main outcome
healing of fissure or fistula
Quality
This is a general narrative review/opinion piece with no study data, patient numbers, or outcomes reported.
Limitations
No original data, patient numbers, methodology, or follow-up reported; appears to be a clinical overview rather than a study.
Taken word for word from the abstract
- population Anal fissures and fistulas
- intervention An acute fissure often heals in a month with conservative management
- intervention Chronic fistula in ano requires fistulotomy, which can be done with a local anesthetic
- comparator An acute fistulous abscess must be drained by unroofing the abscess rather than by simple incision, which fosters recurrence
- primaryOutcome An acute fissure often heals in a month with conservative management
- result long-standing disease is relieved by lateral internal sphincterotomy
- result Chronic fistula in ano requires fistulotomy, which can be done with a local anesthetic
Postgrad Med · PMID 3671218 · Read it on PubMed ↗
Holland et al. 1983
Perineal Crohn's disease
No healing outcomes reported.Case seriesVery low qualityRelated question
6 people1983
Who was studied
women with Crohn's disease and rectovaginal fistulas
What they received
conservative (non-surgical) management
Compared with
surgical approaches including local repair, proximal diversion, or proctocolectomy
Main outcome
healing of the fistula
Quality
This is a small case series of six patients with no comparison group or reported healing outcomes, so it can't show whether fistulas heal without surgery.
Limitations
No quantitative outcomes reported; focuses on Crohn's-related rectovaginal fistulas in women, a specific subgroup, and is a descriptive case series without controlled comparison.
Taken word for word from the abstract
- population Six cases of presumptive or documented Crohn's disease associated with rectovaginal fistulas
- intervention Conservative management is stressed in view of the poor healing characteristics of perineal tissue in these patients.
- comparator Alternative surgical approaches, including local repair, proximal diversion, and curative total proctocolectomy/ileostomy, are presented.
- primaryOutcome Local repair is fraught with problems including postoperative breakdown and recurrence, yet proctocolectomy is a radical, but curative, procedure.
- n Six cases of presumptive or documented Crohn's disease associated with rectovaginal fistulas
Obstet Gynecol · PMID 6888834 · Read it on PubMed ↗
Bergstrand et al. 1980
Outcome following treatment of anal fistulae in Crohn's disease
Some fistulas healed without surgery.Case seriesVery low qualityRelated question
24 people1980
5 of 7 treated conservatively healed; 10 of 13 treated with local surgery healed; 4 with rectal involvement needed major excision surgery
Who was studied
patients with anal fistulas caused by Crohn's disease
What they received
conservative (non-surgical) treatment or local surgery
Compared with
conservative treatment versus local surgery versus major surgery (abdominoperineal excision)
Main outcome
whether the fistula healed
Quality
This is a very small, old case series without randomization or control groups, so it cannot reliably show whether one treatment works better than another.
Limitations
Small sample of 24 patients, no randomization, no control group, and population limited to Crohn's disease-related fistulas rather than fistulas in general.
Taken word for word from the abstract
- n The results of treating 24 patients with anal fistulae and active intestinal Crohn's disease is reported.
- population 24 patients with anal fistulae and active intestinal Crohn's disease
- intervention Seven patients with only minor discomfort were treated conservatively and five of them healed.
- comparator Thirteen were treated by local surgery and ten subsequently healed.
- primaryOutcome five of them healed
- result Seven patients with only minor discomfort were treated conservatively and five of them healed. Thirteen were treated by local surgery and ten subsequently healed.
Acta Chir Scand Suppl · PMID 6939193 · Read it on PubMed ↗
Kovalcik et al. 1979
Anorectal abscess
Surgery urged; nonsurgical care caused delays.RetrospectiveLow qualityRelated question
181 people1979
delays occurred when nonoperative management was tried, and postoperative recurrence rate was at least 6 per cent
Who was studied
patients admitted with anorectal abscesses
What they received
prompt incision and drainage surgery
Compared with
nonoperative management
Main outcome
recurrence rate after treatment
Quality
This is an old retrospective chart review of abscesses, not a controlled study of fistula healing, so it can't show whether fistulas heal without surgery.
Limitations
Retrospective review describing abscess (not fistula) patients, with delays attributed partly to attempted nonoperative management, no control group or statistical comparison.
Taken word for word from the abstract
- n 181 admissions
- population anorectal abscesses
- intervention Treatment should be prompt incision and drainage under spinal or general anesthesia.
- comparator attempts at nonoperative management
- primaryOutcome These abscesses are notorious for the recurrence rate after treatment.
- result Delays in treatment occurred because of misdiagnosis, attempts at nonoperative management and inhospital procrastination.
- result a postoperative recurrence rate of at least 6 per cent
Surg Gynecol Obstet · PMID 505265 · Read it on PubMed ↗

How we searchedThe exact query, the date it ran, and what came back — so you can run it yourself.

Searched: PubMed · ClinicalTrials.gov · Crossref on 2026-10-05
The exact search — paste this into PubMed to repeat it: ("Rectal Fistula"[Mesh] OR "anal fistula"[tiab] OR "fistula-in-ano"[tiab] OR "fistula in ano"[tiab]) AND ("conservative treatment"[tiab] OR "conservative management"[tiab] OR "nonoperative"[tiab] OR "non-surgical"[tiab] OR "without surgery"[tiab] OR "medical management"[tiab] OR "antibiotic therapy"[tiab] OR "watchful waiting"[tiab]) AND ("healing"[tiab] OR "closure"[tiab] OR "recurrence"[tiab] OR "outcome"[tiab]); PubMed expanded that to: ("Rectal Fistula"[MeSH Terms] OR "anal fistula"[Title/Abstract] OR "fistula-in-ano"[Title/Abstract] OR "fistula-in-ano"[Title/Abstract]) AND ("conservative treatment"[Title/Abstract] OR "conservative management"[Title/Abstract] OR "nonoperative"[Title/Abstract] OR "non-surgical"[Title/Abstract] OR "without surgery"[Title/Abstract] OR "medical management"[Title/Abstract] OR "antibiotic therapy"[Title/Abstract] OR "watchful waiting"[Title/Abstract]) AND ("healing"[Title/Abstract] OR "closure"[Title/Abstract] OR "recurrence"[Title/Abstract] OR "outcome"[Title/Abstract])
What came back: 114 records found · 114 read · 80 answered the question
Included: Human, animal or laboratory studies reporting an outcome relevant to the question
Excluded: Records about a different condition or intervention
Records reporting no outcome
Retracted publications, which are listed but excluded from every count
Limits: Details were read from abstracts, not full papers, so anything reported only in a paper's methods section is not captured here.
Fields were read from abstracts, not full text, so detail reported only in a paper's methods section is not captured.
Evidence strength is adapted from the GRADE framework. It is not a GRADE assessment and was not produced by a GRADE panel.

114records came back from the search
114were read
80actually answered the question

Common questionsShort answers, drawn from the same studies.

Will my anal fistula heal if I just wait?: Based on the limited evidence available, that's unlikely. A review of anal fistula treatment states these tunnels usually do not close on their own, and waiting can let infection and symptoms continue.
Should I stop non-surgical treatment and have surgery instead?: If you're currently relying only on antibiotics or watchful waiting, talk to a colorectal surgeon. The limited evidence available suggests surgery closes fistulas more reliably than non-surgical options, though the quality of that evidence is very low.
Is a fistula plug a good alternative to surgery?: A combined analysis of earlier studies found fistula plugs came back more often than fistulas treated with surgery (about 62% versus 47%), though rates of bowel-control problems were similar either way.
Can antibiotics alone cure a fistula?: The evidence available suggests antibiotics are not generally effective on their own at curing an anal fistula, except in specific situations your doctor would identify.
Why is the evidence about this so weak?: Only two studies were found that directly compare non-surgical and surgical treatment in adults with this type of fistula, neither is a randomized trial, and other smaller studies don't fully agree with them — so confidence in any conclusion is very low.

This is information, not advice

This page summarises published research. It cannot tell you what is happening in your own body, and evidence changes. If something is bleeding, painful, or new, it is worth being looked at — that is a different question from the one on this page, and a better one to bring to a consultation.

Contact the office

Automated evidence review — PubMed, ClinicalTrials.gov, Crossref. Search strategy, grading rules and the checks that must pass before anything publishes were written by Allen Kamrava, MD, MBA, FACS, FASCRS, colon & rectal surgery, Beverly Hills. The pages themselves are compiled by software running that method and are not read one by one before publication — saying otherwise would be the one claim here that could not be checked.

Allen Kamrava, MD, MBA, FACS, FASCRS · 435 N. Bedford Dr., Suite 308, Beverly Hills, CA 90210 · 424.279.8222

Educational information — not medical advice.