Management of recurrent anal fistula

Recurrence after surgical treatment of fistula-in-ano is related to the complexity of the fistula, the surgeon performing the procedure, and the surgery used to treat the fistula. The clinical evaluation of a patient with recurrent fistula-in-ano must exclude other diagnoses, seek to identify the cause of the recurrence, delineate the anatomy of the fistula, and assess the patient's continence. Endorectal ultrasonography and magnetic resonance imaging may help to define the anatomy of the fistula. The effective surgical treatment requires identification of the primary tract and lay open and marsupialization of all secondary extensions. Low fistulas can be safely treated by fistulotomy with or without seton. Because of the risk of incontinence, high anal fistulas should be treated by techniques that do not divide the sphincter complex.