What could be causing my difficulty defecating, pain on a previous scar near the anus, and history of drainage?

Chronic Anal Fistula with Recurrent Abscess

You have a chronic anal fistula, which is a persistent tract connecting the anal canal to the perianal skin, resulting from your previous abscess that was drained. 1

Understanding Your Condition

Your constellation of symptoms—difficulty defecating, pain at a previous scar near the anus, and history of drainage—is pathognomonic for a chronic anal fistula that developed after your initial anorectal abscess. 1

Why This Diagnosis Fits

• Approximately one-third of anorectal abscesses lead to fistula formation, and the majority of anal fistulas arise from preexisting abscesses through the cryptoglandular mechanism (infection of anal glands at the dentate line). 1

• The absence of acute infection signs (no current swelling, fever, or systemic symptoms) indicates you have a chronic fistula rather than an active abscess. 1

• Perianal fistulas are detected in approximately 50% of cases after drainage of a perianal abscess, and your recurrent symptoms strongly suggest fistula formation. 1

• The recurrence rate after simple abscess drainage can be as high as 44%, with inadequate drainage, loculations, and time from disease onset to incision being key risk factors. 2

Most Likely Fistula Type

Based on your description of a cord-like scar structure near the anus, you most likely have an intersphincteric fistula—a tract running between the internal and external anal sphincter muscles. 1 This is distinguished from:

• Ischiorectal fistulas, which penetrate through the external sphincter into the ischioanal space and would present with more lateral extension 1
• Supralevator abscesses, which would present with a palpable mass above the levator ani muscle 1

Critical Next Steps

Mandatory Evaluation for Crohn's Disease

You must be evaluated for underlying Crohn's disease, especially given your recurrent presentation. 1 This is mandatory because:

• Perianal Crohn's disease must be excluded in every patient with recurrent anorectal abscess or fistula 3
• Your physician should assess for inflammatory bowel disease symptoms including diarrhea, weight loss, abdominal pain, and other systemic manifestations 1
• Look for surgical scars, anorectal deformities, and other signs of perianal Crohn's on careful perineal inspection 3

Required Imaging Before Surgery

You need preoperative imaging with MRI or endoanal ultrasound for surgical planning. 1 This is essential because:

• MRI shows higher accuracy for complex fistulae and secondary extensions 1
• Imaging is indicated for recurrence, suspected inflammatory bowel disease, and evidence of fistula with non-healing wound 2
• CT can provide important information about the underlying etiology and detect the course and locations of fistulae 1

Definitive Treatment

Surgical management is required for definitive treatment of your chronic fistula. 2 Medical management alone will not resolve an established fistula tract. The surgical approach depends on:

• Fistula classification (intersphincteric vs. transsphincteric vs. other types) determined by imaging 1
• Presence or absence of Crohn's disease, as this fundamentally changes management strategy 1
• Relationship to the anal sphincter complex to minimize risk of fecal incontinence 2

If Crohn's Disease is Present

• Perianal fistulae in Crohn's disease are treated conservatively with medical therapy 4
• Surgery is only required for abscess drainage, not for the fistula itself 4

If Cryptoglandular (Non-Crohn's) Fistula

• Surgical techniques must balance complete fistula treatment with sphincter preservation 2
• The internal opening at the dentate line is the pathognomonic feature that guides surgical approach 1

Common Pitfalls to Avoid

• Do not assume this is just hemorrhoids or a simple anal fissure—the history of previous drainage with recurrent symptoms is diagnostic for fistula. 1
• Do not delay evaluation for Crohn's disease—this changes the entire treatment paradigm from surgical to medical management. 1
• Do not proceed to surgery without imaging—blind surgical exploration of complex or recurrent fistulas risks sphincter damage and treatment failure. 1
• Do not accept simple incision and drainage again—this will only provide temporary relief and the fistula will recur without definitive fistula surgery. 2