New guidelines address treatment of anorectal abscesses, anal fistulas and rectovaginal fistulas

The American College of Colorectal Surgeons has issued updated guidelines for physicians, diseases of the colon and rectumdescribes how to treat anal and rectal problems called anorectal abscesses, anal fistulas, and rectovaginal fistulas.

The guidelines were developed by a panel of expert colorectal surgeons led by Daniel L. Feingold, MD, of Rutgers University. Committee members reviewed 267 medical and surgical studies and updated guidelines previously published in 2016. The new guidelines address four topics detailed below.

New Crohn’s disease recommendations

Anal fistulas associated with Crohn’s disease – Crohn’s disease is a chronic disease that causes persistent inflammation in the gastrointestinal tract. Anorectal abscesses and anal fistulas are common in patients with Crohn’s disease and are thought to be caused by osmotic inflammation rather than infection.

The new guideline recommendation is that anal fistulas in Crohn’s disease should usually be treated with both surgery and drug therapy. The most well-studied drugs are infliximab and adalimumab, which have strong anti-inflammatory effects. Surgery is usually followed by antibiotic treatment. The surgeon may place a drainage seton, surgical thread, or a very small silicone drain that is left within the fistula canal to aid drainage from the fistula. Seton may be used for long-term disease control. In extreme situations, some patients with severe anal fistulas eventually require part or all of their rectum to be removed and the stool permanently transferred to a stoma bag.

The new guideline-approved treatment for anal fistulas involves administering stem cells to repair damaged tissue. This approach is not widely available. However, studies are being conducted in patients with Crohn’s disease.

New treatment guidelines for anal and rectal problems

Anorectal abscess – An anorectal abscess is a pus-filled pocket near the anal opening or deeper toward the rectum caused by a bacterial infection. It is generally treated with prompt incision and drainage. New guidelines recommend reserving antibiotics for patients with certain comorbidities.

Anal fistula – After successful treatment of an abscess, approximately 30% to 70% of patients may develop an anal fistula, which is an abnormal tunnel connection between the skin around the anus and the anal canal. Fistulas usually require surgery, and new guidelines provide updated suggestions for a variety of possible treatments and approaches. A new section of the guidelines describes minimally invasive surgery for anal fistulas that involves the use of an endoscope or laser. Although short-term cure rates are promising in recent studies, long-term cure and recurrence rates are unknown.

Rectovaginal fistula – A rectovaginal fistula is an abnormal connection between the anus and vagina, or the rectum and vagina. Intestinal contents may leak through the fistula, allowing gas and stool to pass through the vagina. Rectovaginal fistulas usually occur as a result of obstetric injury, but can also be associated with Crohn’s disease, cancer, or infection. Surgery is often required, and as with anal fistulas, severe cases may require partial or complete removal of the rectum.

Benign and less bothersome rectovaginal fistulas can usually be treated for 3 to 6 months with bathing, wound care, antibiotics (in case of infection), and fiber supplements to increase stool size.

Clinical judgment remains important

Dr. Feingold and his colleagues stress that the guidelines do not prescribe specific treatments for these conditions. “The final judgment regarding the appropriateness of a particular procedure must be made by the physician, considering all the circumstances presented by the individual patient.”