What is the treatment for a rectal fistula?

From the Guidelines

The treatment for a rectal fistula typically involves surgical intervention, with the specific approach depending on the fistula's location, complexity, and underlying cause, and the most recent guidelines suggest performing a fistulotomy at the time of abscess drainage only in cases of low fistula not involving sphincter muscle, as recommended by the WSES-AAST guidelines 1. The primary surgical options include:

• Fistulotomy (opening the fistula tract)
• Seton placement (inserting a thread to drain the infection)
• Advancement flap procedures (covering the internal opening with tissue)
• LIFT procedure (ligation of intersphincteric fistula tract) Before surgery, antibiotics such as metronidazole (500mg three times daily for 7-10 days) or ciprofloxacin (500mg twice daily for 7-10 days) may be prescribed to control infection, as suggested by various studies 1. For patients with Crohn's disease-related fistulas, medical management with immunosuppressants like infliximab (5mg/kg intravenous infusion at weeks 0,2, and 6, then every 8 weeks) or adalimumab (160mg initially, 80mg at week 2, then 40mg every other week) may be necessary, as recommended by the ECCO-ESCP consensus on surgery for Crohn's disease 1. Post-surgical care includes:
• Sitz baths 2-3 times daily
• Regular dressing changes
• Pain management with acetaminophen or NSAIDs
• Maintaining good hygiene Surgery aims to eliminate the fistula while preserving sphincter function to prevent incontinence, with healing typically taking several weeks to months depending on the procedure performed, and the most recent study suggests that seton placement with anti-TNF therapy may be a viable option for some patients 1.

From the Research

Treatment Options for Rectal Fistula

The treatment for a rectal fistula can vary depending on the type and severity of the fistula. Some of the treatment options include:

• Surgical procedures such as fistulotomy, which is considered the gold standard for low and simple fistulas 2
• Conservative and palliative approaches, such as incision and drainage of abscesses or prolonged non-cutting seton placement, for high and complex fistulas 2
• Definitive procedures, including mucosal advancement or dermal island flaps, the use of plugs or glue, video assisted anal fistula treatment, ligation of the intersphincteric track, and vacuum assisted closure 2
• Medical therapy, such as antibiotics, to adjuvantly treat the fistula 3

Medications Used in Treatment

Some medications that have been used to treat rectal fistulas include:

• Ciprofloxacin, which has been shown to be effective in treating perianal fistulas in patients with Crohn's disease 3
• Metronidazole, which has also been used to treat perianal fistulas, although its effectiveness is less clear 3

Surgical Techniques

Various surgical techniques have been developed to treat rectal fistulas, including:

• Rectovaginal fistula repair, which can be performed using different surgical techniques, such as advancement flaps or interposition grafts 4
• Rectourethral fistula repair, which can be performed using techniques such as diverting colostomy, urethral catheterization, and gracilis muscle flap 5, 6
• Staging systems, such as the one developed for rectourinary fistulas, can help guide surgical treatment and improve outcomes 6