What is the best treatment approach for a patient with an Adult Baby Diaper Lover (ABDL) fetish and a fistula?

Treatment of Fistula in a Patient with ABDL Fetish

The treatment approach for a fistula in a patient with ABDL fetish is identical to standard fistula management, with the primary consideration being fistula type and location—the fetish itself does not alter medical or surgical treatment protocols, though meticulous wound care and hygiene counseling become particularly critical given the patient's diaper use.

Initial Assessment and Classification

The first step is determining the fistula type and complexity through physical examination and imaging:

• Perianal fistulas should be classified as simple (low, single tract, minimal sphincter involvement) versus complex (high, multiple tracts, significant sphincter involvement) 1
• Non-perianal fistulas (enterocutaneous, enterovesical, enterovaginal) require identification of associated complications including abscesses, strictures, and underlying inflammatory bowel disease 1
• Digital rectal examination is essential for perianal disease 2
• MRI, CT, or endosonography should be obtained for complex cases or when clinical examination is inadequate 2, 3

Treatment Algorithm by Fistula Type

Simple Perianal Fistulas

For simple perianal fistulas, treatment options include:

• Fistulotomy can be performed at the time of abscess drainage if a low fistula not involving sphincter muscle is identified 2, 3
• Antibiotics (metronidazole and/or ciprofloxacin) are widely used but lack placebo-controlled trial evidence 1
• Infliximab has FDA approval with proven efficacy in placebo-controlled trials for fistula reduction and maintenance (3-dose induction, then every 8 weeks) 1
• Insufficient evidence exists to definitively rank these options, but surgical fistulotomy achieves high sustained healing rates for truly simple fistulas 1

Complex Perianal Fistulas

For complex perianal fistulas involving sphincter muscle:

• Place a loose draining seton rather than performing immediate fistulotomy to prevent incontinence 2, 3, 4
• Avoid probing to search for a fistula if one is not obvious, as this causes iatrogenic complications 2
• Infliximab is the only medical therapy with placebo-controlled trial evidence showing reduction in draining fistulas and maintenance of that reduction 1
• Antibiotics and immunomodulators (azathioprine, 6-mercaptopurine) are adjunctive but lack primary endpoint evidence for fistula closure 1
• Surgery is largely palliative; abscesses must be drained and setons placed for ongoing drainage 1

Non-Perianal Fistulas (Enterocutaneous, Enterovesical, Enterovaginal)

For enterovaginal and enterovesical fistulae, joint medical control of inflammation and surgical resection is recommended 1

For enterocutaneous fistulae:

• Low-volume fistulae may be controlled with immunomodulator and biological therapy 1
• High-volume fistulae usually require surgery for symptom control 1
• Initial management requires nutritional and biochemical optimization, sepsis control, and drainage of collections before definitive surgery 1
• Anti-TNF therapy should only be started after abscesses have been treated with antibiotics and drainage 1
• One-third achieve fistula healing with anti-TNF therapy, but half relapse over 3 years; 54% ultimately require surgery 1
• All patients require multidisciplinary team management given mortality risk with increasing complexity 1

Critical Considerations for ABDL Patients

Hygiene and Wound Care

The continuous diaper use in ABDL patients creates unique challenges:

• Meticulous perianal hygiene is essential—clean the area gently after each bowel movement using warm water without harsh soaps 4
• Sitz baths with warm water for 10-15 minutes, 2-3 times daily to keep the area clean and reduce inflammation 4
• Non-adherent dressings should be applied if significant drainage is present to prevent skin maceration 4
• The moist, occlusive environment of diapers increases infection risk and impairs wound healing—patients must be counseled on frequent diaper changes and barrier creams

Infection Prevention

• Antibiotics are not routinely indicated for adequately drained anorectal abscesses in immunocompetent patients 2
• However, antibiotic administration is recommended for immunocompromised patients or those with sepsis 2
• When indicated, empiric broad-spectrum coverage should include Gram-positive, Gram-negative, and anaerobic bacteria 2
• The diaper environment may warrant lower threshold for antibiotic use given increased bacterial colonization

Abscess Management

If abscess is present:

• Surgical incision and drainage is definitive treatment for all anorectal abscesses 2, 3
• Timing depends on sepsis severity—emergent drainage for sepsis, immunosuppression, diabetes, or diffuse cellulitis 3
• Keep incision as close as possible to anal verge to minimize potential fistula length 3
• Check for undetected diabetes mellitus (common comorbidity) with serum glucose, hemoglobin A1c, and urine ketones 2

Post-Treatment Monitoring

• Monitor for decreased drainage as a positive sign of improvement 4
• Watch for increasing pain, swelling, redness, fever, or purulent discharge requiring immediate medical attention 4
• Regular follow-up is essential to determine appropriate timing for seton removal if placed 4
• Recurrence risk after drainage alone can be as high as 44% 3

Common Pitfalls

• Do not perform fistulotomy on complex fistulas involving sphincter muscle—this causes incontinence 2, 3
• Never start anti-TNF therapy before treating abscesses with drainage 1
• Avoid surgical treatment of perianal skin tags as this leads to chronic non-healing ulcers 4
• The ABDL fetish itself requires no specific psychiatric intervention unless the patient requests it—focus remains on surgical/medical fistula management 5