Anal fistula - Treatment 

Treating an anal fistula 

Waiting times

If your GP refers you for treatment, you have the right for any non-emergency treatment to start within a maximum of 18 weeks.

If this is not possible, the NHS must take all reasonable steps to offer you a range of suitable alternative providers. 

Read about the NHS Constitution and NHS waiting times.

Surgery is usually necessary to treat an anal fistula as very few heal by themselves.

The type of surgery you have will depend on the position of your fistula and whether it is classed as simple or complex. Your surgeon will be able to explain the procedure to you in more detail.

Surgery

The aim of surgery is to heal the fistula while avoiding damage to the sphincter muscles (the ring of muscles that open and close the anus). Damage to the sphincter muscles could lead to bowel incontinence, where you do not have control over your bowels.

Read more about complications of an anal fistula.

Surgery for an anal fistula is usually carried out under a general anaesthetic, where you are unconscious and cannot feel anything. In some cases a local anaesthetic is used, where you are conscious but the area being treated is numbed so you do not feel any pain.

Some of the different types of anal fistula surgery are explained below.

Fistulotomy

A fistulotomy is the most commonly used type of anal fistula surgery, used in 85-95% of cases.

It involves cutting open the whole length of the fistula, from the internal opening to the external opening. The surgeon will flush out the contents and flatten it out. After one to two months, the fistula will heal into a flat scar.

To access the fistula, your surgeon may have to cut a small portion of the anal sphincter muscle. However, this will depend on the position of the fistula. Your surgeon will make every attempt to reduce the likelihood of bowel incontinence.

Seton techniques

Your surgeon may decide to use a seton during your surgery. A seton is a piece of surgical thread that is left in the fistula tract to keep the tract open, often for several months. This allows it to drain properly before it heals.

This may be considered if you are at high risk of developing incontinence – for example, because your fistula crosses your sphincter muscles.

It is also sometimes used to allow secondary tracts to heal before further surgery is carried out on the main tract. It can also be used to divide the sphincter muscle, which allows it to heal between operations.

If your surgeon is planning to use a seton, they will discuss this with you. In some cases, it may be necessary to have several operations to treat your fistula using seton techniques. 

Advancement flap procedures

Advancement flap procedures may be considered if your fistula is complex or there is a high risk of incontinence.

An advancement flap is a piece of tissue that is removed from the rectum or from the skin around the anus.

During surgery, the fistula tract is removed (a procedure called fistulotomy). The advancement flap is then attached to where the internal opening of the fistula was.

Bioprosthetic plug

A bioprosthetic plug is a cone-shaped plug made from animal tissue. It can be used to block the internal opening of the fistula.

Stitches are used to keep the plug in place, but the external opening is not completely sealed so the fistula can continue to drain. New tissue then grows around the plug to heal it.

However, this procedure can sometimes lead to complications, such as:

  • pain and increased drainage – this may require treatment with antibiotics
  • a new abscess forming
  • the plug being pushed out of place

Read the National Institute for Health and Care Excellence (NICE) guidance on closure of anal fistula using a suturable bioprosthetic plug.

Two trials using bioprosthetic plugs have reported success rates of more than 80%. However, there is still uncertainty over the recurrence rates and long-term outcomes.

Non-surgical treatments

Fibrin glue

Fibrin glue is currently the only non-surgical option for treating an anal fistula. The fibrin glue is injected into the fistula to seal the tract. It is injected through the opening of the fistula and the opening is then stitched closed.

Fibrin glue may seem an attractive option as it is a simple, safe and painless procedure. However, the long-term results for this treatment method are poor. For example, one small study had an initial success rate of 77%, but after 16 months only 14% of people were still successfully healed.

Ongoing research

Several clinical trials are currently taking place to compare the different types of treatment for an anal fistula. You may be asked to take part in one.

Read more information about taking part in a clinical trial.

If you are interested, you will be given information about the particular trial and asked for your consent.

Before giving your consent, make sure that you are fully aware of everything the trial involves. Feel free to decline if you do not wish to take part.

Read a list of current clinical trials for anal fistula.

Page last reviewed: 20/06/2014

Next review due: 20/06/2016

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Comments

The 21 comments posted are personal views. Any information they give has not been checked and may not be accurate.

Sad and upset said on 17 September 2014

Im sad and upset. I cant stand the Seton tightening anymore. I have had enough. The first three days after the operation I have learned now that I cannot move from my house. I am sore, upset, very devasted that the stitch cannot be removed just yet. This has been going on since May this year. Im at a loss

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Ruby Z said on 28 August 2014

I wanted to tell people that it's not really that bad and not to panic. I looked for hours on end trying to read up on it and the possibilities and I scared myself silly so I thought I'd let you know some good news as people normally post bad. I am an out going 24yrd old and compete horses at a high level I thought it was over when i read what people has wrote and that I'd never ride a horse again. I have had currently a Fistulotomy for one fistula on March and now currently have a cutting seton stitch in for the second one. After both surgeries so far it's been not bad at all. My first Fistulotomy has heeled up and gone it wasn't pleasant but it wasn't that bad. After 9 days from having the cutting seton put in I sat on one of my horses which I never thought I would be able to do. Fingers crossed that the rest of the surgery is like these two experiences. Many thanks

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MEiEatDust said on 21 August 2014

Hi all, I came across this site back in Jan. I was looking for some info on setons as I was having one put in. Like some other people I didn't know much about it and didn't really understand what it was, I just knew it was surgical thread going through the fistula. Anyway, I had the procedure in Feb. I never had any stabbing pains like some other folk. There was some discomfort but not bad enough for me to take pain relief. The main problem I had was 'toileting.' I ended up visiting the hospital with constipation. That caused me the most pain. Anyway, after that was sorted out, I was fine. Its important to keep the area clean and I always wore a sanitary pad for the leakage which did stop. I was off my work (manual job) for approx. 2 weeks then back to normal.
In May this year, I had the seton removed and the fibrin glue put in. I think this is a fairly new procedure. Again, I didn't need the pain relief I was given (Tramadol) . This time I was prepared for any constipation problems (took my laxido and plenty prunes with cream). Its been nearly 3 months now and I'm going for my 2nd follow up in September with the Consultant. I still wear a sanitary towel everyday but its not a problem. The only issue I seem to have is my obsession with knowing where the toilets are wherever I go Lol. Anyway, sorry for rambling, but maybe my experience will help someone else. I also came across a Chrohns website that had some great info. I just hope that this Fibrin plug works for me. :)

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Teififisher said on 09 August 2014

I have just been told have a fistula and will need surgery to have it removed. But can anyone suggest a few simple things to do to relieve the intense pain that I can sometimes have passing stools and also (usually) the pain that comes on half and hour or an hour after going to the loo? I'd be really grateful for any suggestions of things that have brought some relief to fellow sufferers. Thanks

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emmyjean said on 21 July 2014

I am interested to know and find out how everyone is doing? My other half is plagued with this abomination. Hes had 3 surgeries now, the 1st 2 to cut and drain and the 3rd a Seton. He has now been referred to a specialist for a 2nd opinion on what to do and the 'plug' was mentioned.
What is the overall opinion on the plug? The other options could make him incontinent....so naturally we don't want that to happen....

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jimmo44 said on 09 July 2014

They will usually have the seton to clear out the track. That's what they did first, then they put in the implant but I got a bad infection, I had to have another drain cut as it had sealed up. Then the implant failed and the long tube seemed to be irritating the external exit, the one on the cheek. It got so bad I went back and he's go rid of most of it. I really think that the only way is to have the fistula cut out or flattened because all other treatment depends too much on sterility which in this area is way too dodgy. Washing is really crucial and I bought on of those toilet bidets; its just like a bowl that fits on the seat and you sit on it. It makes hygiene so simple and brings a lot of relief. Don't be disheartened, just make sure your surgeon agrees a best plan of action for you and wash until your bum is wrinkly! Good luck Woodberry and Carly alike and all those who just read for the info. I'll keep in touch.

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jimmo44 said on 09 July 2014

I went in yesterday to have the implant removed and a partial fistulotomy and and a smaller seton souture in preparation for the final bit to be removed and the relief is fantastic. Most times only excision or flattening really work so far.

Anyway just wanted to update you. Things seem to have gone a little quiet, I hope I didn't upset anyone.

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woodberry73 said on 09 July 2014

Oh dear I am so sorry to hear that.
What were the previous operations if you don't mind saying.
I am finding this all too horrible. No one seems to have anything good to say about any of the procedures and so many seem to fail.

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jimmo44 said on 06 July 2014

I had a collagen implant in January as part of a trial. It is the FIAT trial and treatment is decided on a draw. Anyway, my surgeon told me to be optimistic but told me that of the five or so operations, none had concluded successfully. So I really went in thinking I would prove him wrong and would be his first success.

Unfortunately, this was not to be the case. The pain over the next few months was unbearable and leakages kept occurring. I couldn't return to work and ended up being dismissed. Only now am I able to return to hospital to have another Seton suture. After that I don't know as I've already had four operations. So just bear in mind that although the plug sounds a really good idea, it may not live up to its reputation. Good luck.

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woodberry73 said on 05 July 2014

Glad to hear the recovery is going well.
Where are you based out of interest? As I don't believe everywhere offers the plug. I am hoping for this procedure but I am worried as the success rate is not that high. Currently have a seton and the pain is awful. Can't wait for it to go but am scared a plug will cause more problems.

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Carly L said on 29 June 2014

Tomorrow I will be 4 weeks post surgery. I have managed to walk a lot better over the last week although I still tire quickly. I am taking less pain killers but am still getting stinging pains after each BM and an ache in the bottom cheek as has always been the case for the past year. The plug is still in place and there are stitches poking out from my anus, I hardly know they are there and refuse to tug at them just in case, they are dissolvable and may drop out or dissolve eventually. I am still discharging from the wound site particularly after a BM and wear a flat cotton pad to catch the residue. My donut pillow has been heaven for being back at work to sit on and I got a perianal ligation bottle- essentially a squeezy bottle which I fill with warm water whilst out and about and spray onto the wound to keep it clean until I can get home to clean properly. A hot water bottle also dulls the ache/throbbing if required.

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woodberry73 said on 19 June 2014

Carly L
I would be interested to hear more about your recovery from seton the plug as believe I will have this too.

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Carly L said on 12 June 2014

Update- I had a seton in place for 7 months and I am just in recovery from having a bio plug fitted into the tract. The recovery has been very slow and painful although not as bad as the initial abscess pain and operation. I am very swollen around the rectum/anus but the wound sight seems fine although much larger than I anticipated due to giving the tract the best chance to drain. I would like to warn anyone who has this procedure that a cream coloured mucus like jelly substance comes out of the wound site and sticks to the skin around the wound- I rang my surgeon and he said this is perfectly normal and would eventually slide away, three days later it came away. I would be really interested to hear from The birch who had one fitted too or anyone else who has had this procedure done. I have been off work for two weeks and have another few days left to recover. As with all these operations the worse part is going to the toilet afterwards and getting used to the routine. I still swear by my portable bidet and my doctor advised me to use water wipes rather than baby wipes as they are pure and they are much better for open wounds.

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Callyho84 said on 03 April 2014

I had my first follow up appointment last week - about 3 months after my Seton was placed. Really quick exam and my surgeon said the healing is looking good. Next step is that I need to have an MRI to see what my fistula is up to - how deep it is, what muscles are involved etc. then they will decide which is the best next surgery to do - fistulotomy, advancement flap or bio-prosthetic plug. I will post again after the MRI!

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tippy1 said on 03 March 2014

I just had a seton inserted on 28 Feb following a peri anal abcess. I am glad I have found these comments as although I discussed with my surgeon, you don't really know what to expect after surgery. You do not know who to turn to with any questions. My main pain seems to be from the site of the abcess which is still tender (this was drained on 15 Jan and packed for about 5 weeks) the seton is uncomfortable and I am finding it awkward going to the loo. I am an office worker and my job involves sitting all day which is very painful but I don't know how long I should reasonably stay off as feel ok otherwise. Any tips? I do feel as if this is dominating my life at the moment.

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Callyho84 said on 26 January 2014

Hi there, I also had surgery on my fistula in December 2013 and had a seton fitted.
This was my third surgery - the first two were both 'emergency' surgery to open up a peri anal abscess and this latest one is the first scheduled attempt at rectifying the fistula problem that developed from said abscess.

I would agree that I don't feel like I was given enough information prior to my surgery. I was told that if the fistula is too deep then I would need a seton, but didn't really understand what it was or how it worked. Needless to say, I was a little shocked and upset when I got home and discovered that I had what looks like an elastic band tied in a loop through my bottom and then out through the surgical opening in my skin!

If you are reading this before surgery then well done for doing some research. Make sure you ask lots of questions to your surgeon before the procedure, I didn't see mine after and wasn't given any info.

After the initial shock of the seton I have not found recovery to be too bad. Similarly to the post below I had sharp shooting pains for a while as the surgical opening healed. I'm about 6 weeks in now and have very little pain, the wound is healed as much as it can be with the seton in it and I just get some oozing. I use non adherent dressings which I can tuck in between my cheeks to soak up any mess. I find this dryer and more comfortable than sanitary towels. I read that oil of oregano is good for healing so I take tablets of that daily (I worry I smell like a pizza but it's worth a try) and I take vitamin C, try to eat healthily. I use moist toilet tissues and try to have lots of baths.

My next clinic appointment is in March and I have no idea what happens next - I will update. I have read lots of horror stories so I wanted to share that my experience has been ok so far - a pain in the bum, but ok! Good luck all!

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The Birch said on 29 December 2013

I had suffered for years until I was referred to my existing surgeon. A seton was inserted in February 2012. I thought it was only going to be for 3 months, but due to slow healing and a number of cancelled follow up appointments I am only now having the bio prosthetic plug fitted (tomorrow - 30/12/2013). In addition to the fistula I had an abscess, which I am confident has healed, so I hope this final procedure will do the trick. Whilst the seton has been in place I have suffered with discomfort and reoccurring bursting. I hope the plug will stop the pain and infection and bursting. I hope there is light at the end of the tunnel. I have read about the problems with surgery, so if this works then the time taken and discomfort will have been worthwhile. I have been disappointed with the lack of information from the medical profession about what to expect regarding post medical procedures, I think patients need to be better prepared. I hope to update in the future with a positive outcome and a healed fistula - I'll be like a new man !

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Chandra123 said on 29 December 2013

I had Fistulotomy using Seton techniques on 17 December 2013. After the operation I was given a letter to take to my GP's nurse to check my wound. Strangly, no one from the hospital given me any feedback about the operation. The GP nurse was useless and didn't know anything about the Seton. I am very reluctant to go back to my GP nurse and don't know where to get information about Seton. How long do I have to keep the Seton, who is qualified to remove it when required etc. I would be grateful if anyone could let me know where I could these information. By the way, I am computer programmer and my job involves in sitting in front of the computer more than 8 hours a day. At the moment I can't sit more than a hour and my bum gets hurting. Any advice would be greatly appreciated.

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Carly L said on 27 December 2013

I can swear by a portable bidet and cotton wool pads which I place over the wound as the edges of the seton often dig into my skin. I am nearly 8 weeks into my three months and I have my good and bad days. I only had a week off work with the operation and I manage but the bad days are a bit of a struggle. I also get strange aching down into my thigh on the side where the wound is and my leg sometimes aches too. I also often feel like I am carrying a lead weight in my bottom cheek!!! I had a perianal abscess in June prior to them discovering the fistula after 9 weeks of packing. Has now been six months and strangely my cousin has the same thing and has been off work for 9 months and is on his fourth operation at the end of Jan. My surgeon told me on the day of the seton fitting that he would see me in February and either tighten the seton or most likely fit a bio-plug. I will update here, glad to hear from a fellow sufferer. I wish there was an up to date site to share experiences on.

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danni68 said on 20 December 2013

Hi - I had same procedure done December 13th. Yesterday was follow up and I was convinced that it was worth going back to do a full fistulotomy. It frightens me but the surgeon feels pretty confident it will not affect continence. Looking for sites to chat with others who have had it done to know what to expect. So far my experience has been identical to yours described below. Any suggestions?

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Carly L said on 07 November 2013

I had an examination under anaesthetic and a seton put in place three days ago. I would like to tell anyone else experiencing this- it is not too bad. I have done a lot of research and looked at images that frightened me, however what I have had done is quite simple. Obviously there is pain and getting used to going to the toilet afterwards. I would describe the pain I feel as an open cut that stings and every so often I get a shooting pain up the wound site and my bottom cheeks ache. This pain is more uncomfortable than excruciating and only lasts for short periods. I was walking around slowly an hour after surgery and am still taking things slowly and listening to my body. I am hoping to go back to work a week after the procedure providing I have gotten used to my daily toileting routine-this is the most inconvenient part (obviously).

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