Is fistulotomy the best treatment option for a patient with a history of fistulotomy and a current low transsphincteric fistula who engages in receptive anal sex?

Fistulotomy is NOT the Best Option for This Patient

For a patient with a low transsphincteric fistula who engages in receptive anal sex and has a history of prior fistulotomy, a sphincter-preserving approach using a loose non-cutting seton or LIFT procedure is strongly recommended over fistulotomy to prevent catastrophic incontinence that would severely impact quality of life.

Critical Risk Factors That Contraindicate Fistulotomy

This patient has multiple high-risk features that make fistulotomy dangerous:

• Prior fistulotomy history: The patient has already undergone sphincter division, meaning repeat sphincterotomy would further compromise an already damaged sphincter and make pressure restoration impossible 1
• Receptive anal intercourse: This activity requires intact sphincter function and tone; any additional sphincter division creates unacceptable risk of fecal incontinence during sexual activity
• Transsphincteric involvement: Even "low" transsphincteric fistulas involve external sphincter muscle, and the risk of impaired continence following division is not insignificant, especially in patients with diminished anal sphincter function 2

Recommended Treatment Algorithm

First-Line: Loose Non-Cutting Seton Placement

• Place a loose, low-profile seton made of soft material (fine silastic) through the fistula tract to maintain drainage and prevent abscess recurrence 3
• The seton should run through the sphincter complex ending in the internal opening 3
• Never use a cutting seton, which results in 57% incontinence rates from progressive sphincter transection 3, 1, 4
• Keep the seton in place for variable duration (3 weeks to several months) based on clinical assessment of drainage adequacy and symptom control 3
• Combined seton drainage achieves fistula closure in 13.6-100% of cases and can be definitive treatment 3

Second-Line: LIFT Procedure (If Seton Fails)

• Ligation of the intersphincteric fistula tract (LIFT) is specifically designed for low transsphincteric fistulas and avoids sphincter division entirely 2
• LIFT achieves 82% primary healing rate and 100% overall healing rate when combined with subsequent procedures 2
• This technique preserves continence scores without significant change at 6 months postoperatively 2
• LIFT is essential for patients with compromised anal sphincters, which this patient has from prior surgery 2

Third-Line: Fistulotomy with Immediate Sphincter Reconstruction (Only If Absolutely Necessary)

• If sphincter division is unavoidable, immediate primary sphincteroplasty should be performed simultaneously 5
• This approach demonstrates 93.3% healing rate without increased septic complications (6.7%) 5
• However, this should only be considered if there is no active proctitis and the patient is medically optimized 1

Why Fistulotomy Alone Is Contraindicated

The guidelines are explicit about avoiding fistulotomy in this scenario:

• The American Society of Colon and Rectal Surgeons warns against repeat sphincterotomy in patients with prior fistulotomy 1
• Division of even the lower third of external sphincter carries significant incontinence risk, particularly in patients with diminished sphincter function 2
• The patient's engagement in receptive anal intercourse makes any degree of incontinence functionally devastating for quality of life
• Simple fistulotomy without reconstruction would create a 10-20% risk of continence disturbances 6

Common Pitfalls to Avoid

• Do not probe aggressively to define the tract, as this causes iatrogenic complications 6
• Do not perform aggressive dilation, which causes permanent sphincter injury in 10% of patients 1
• Do not assume "low" means "safe" - any transsphincteric fistula involves sphincter muscle and requires sphincter-preserving approach in high-risk patients 3
• Do not rush to definitive surgery - seton drainage alone can be curative and allows time for inflammation to subside 3