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Recurrent fistula-in-ano is usually due to sepsis missed at surgery, which can be identified by MRI. We aimed to establish the therapeutic effect of MRI in patients with fistula-in-ano. We did MRI in 71 patients with recurrent fistula, with further surgery done at the discretion of the surgeon. Surgery and MRI agreed in 40 patients, five (13%) of whom had further recurrence, compared with 16 (52%) of 31 in whom surgery and MRI disagreed (p=0.0005). Further recurrence in all 16 was at the site predicted by MRI. For surgeons who always acted on MRI, further recurrences arose in four of 25 (16%) operations versus eight of 14 (57%) operations for those who ignored imaging (p=0.008). Surgery guided by MRI reduces further recurrence of fistula-in-ano by 75% and should be done in all patients with recurrent fistula.

The etiology of anorectal abscess and fistula-in-ano is discussed. The anatomy, which is vital to the understanding and treatment of the above, is reviewed, with two of the more common classifications of fistula-in-ano presented. The different methods of treating each are discussed, and some of the common complications of the procedure are listed. A true understanding of the disease process and anatomy is needed before treatment of fistulous abscesses is begun, but, with it, successful outcomes will occur in most cases.