Anal Abscesses & Fistulas

Case study:

“A few weeks ago, I wound up having receptive anal intercourse with a random guy I met on Grindr. I prepared with a Fleet enema and since I am on PrEP and have local irritation from condoms, we barebacked. It was amazing sex. We hit it off and plan on seeing each other again, but after a few days, I started to have anal pain and swelling on the outside of my anus. It really looked like a big red pimple. I knew something was wrong and decided to go to my primary doctor. He quickly sent me to an anal specialist, Dr. Goldstein at Bespoke Surgical, where an anal abscess was diagnosed and may have stemmed from bacterial irritation from the enema or just “raw” friction. It was drained in the office and later found to be a bacterial infection. I was placed on antibiotics and anti-inflammatories. I was relieved when everything subsided, but then a few weeks later, I noticed, at the exact spot where the doctor made the incision, both continued drainage and a pimple that had formed (I was told there was a 50/50 chance that this may happen). I made a follow up appointment and was told the abscess had developed into an anal fistula, which is like a tunnel that connects an internal gland to the external skin of the anus. Clearly, this is not sexy and it halted my anal play completely, and would require surgical correction, but I am so thankful Dr. Goldstein was understanding of my situation and was able to get me riding once again.”

What is an anal abscess/fistula?

An anal abscess is a collection of pus around the rim area caused from a malfunctioning gland. The gland backs up and the fluid finds its way in the tissues to exit near the anal opening. These are usually just luck of the draw, but can occur from inflammatory bowel disease, as well as anal intercourse. Aggressive enema use for preparing for receptive anal intercourse and STD’s can also be the culprit. 50% of abscesses can develop into an anal fistula, which is an infected tunnel that develops between the muscular gland opening at the end of the anal canal and the skin near the anus. Remember most anal fistulas are the result of an infection in an anal gland that initially presented as an abscess and subsequently spread to the skin. Anal fistulas need surgical correction, especially since it is probably limiting anal intercourse and/or anal play.

What are the symptoms of an anal abscesses/fistula?

Anal abscesses are generally associated with a throbbing pain that worsens when sitting. Discharge of pus or blood, constipation or pain with defecation, or anal skin irritation may also be present. An anal fistula is associated mostly with discharge and mild localized skin irritation, along with a hardened tract leading towards the anal opening. This sometimes looks like a large pimple on the exterior aspect of the anus or buttocks.

How are anal abscesses/fistulas diagnosed?

Most anal abscesses/fistulas can be diagnosed by visual inspection. An anoscopy is usually deferred during the abscess period due to significant pain in region and drainage being required. Once a fistula develops, a full anoscopy may be performed in order to localize the internal connection and/or make sure no other pathology is associated.

What is the treatment for an anal fistula?

The appropriate initial regimen to treat an anal abscess/fistula consists of:

  • Over-the-counter stool softeners, such as Colace, three times daily
  • Over-the-counter fiber supplements, such as Metamucil
  • Sitz baths, utilizing over-the-counter epsom salts
  • Boosting your fiber intake with choices such as grains and whole-grain products, fruits, vegetables, legumes, nuts, and seeds
  • Increasing your overall water intake to 8-12 ten ounce glasses per day
  • Refraining from caffeinated beverages, as they tend to cause dehydration
  • Keeping the anal area clean and dry. Wash gently with warm soapy water, and pat dry.
  • Limiting the use of toilet paper, as wiping causes local inflammation. Please refrain from using baby wipes or medicated pads.
  • Antibiotics for most anal abscesses, and sometimes for fistulas due to local inflammation


Anal pathology takes time to heal. You can imagine that every time it is attempting to improve, another local trauma/bowel movement occurs. Do not try to avoid having bowel movements, and try not to get frustrated as you work on the above regimen.

Anal Abscess & Fistula Surgical Treatment

Most anal abscesses require in-office drainage. Sometimes this may require monitored anesthesia care in an ambulatory setting. It is noted to be a 50% chance of complete eradication of the abscess after drainage and a 50% chance of development of an anal fistula. Strategic drainage of the abscess by professionals allows for improved location of fistula formation if this does occur. Generally speaking anal fistulas must be treated surgically, and are characterized as either simple or complex. The vast majority of simple fistulas are treated with a fistulotomy, which involves cutting open the fistula in order for the tract to close. For complex fistulas, a technique commonly practiced involves ligation of the internal fistula tract (LIFT procedure) and removal of the remaining tract. If an abscess and tract is still present during the initial operative evaluation, a seton drain may be placed to allow maturation of this tract, followed by the LIFT procedure mentioned above or use of a cutting seton that is tightened in the office (pulling through the muscle, instead of transecting the muscle in the operating room – super important for our community since it is imperative to keep as much muscle in the game as possible.) Other anal abscess and fistula surgical options are surgical glue and placing an anal fistula plug in the fistula tract, but these do have limited successes.

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Dr. Evan Goldstein, D.O.

Dr. Evan Goldstein, D.O.

Dr. Evan Goldstein is the founder and President of Bespoke Surgical, a surgical practice for modern males based in New York and Los Angeles. He received his medical doctorate from the University of Medicine and Dentistry School of Osteopathic Medicine in 2002. Receiving the highest osteopathic education was pivotal in shaping his holistic whole-life approach towards his practice of private surgical care.

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