Management Recommendations for Low Transsphincteric Fistulotomy Based on Evidence

Recurrence Management

• If a fistula recurs (approximately 3–5% incidence), repeat fistulotomy must be avoided; instead, a loose non‑cutting seton or a Ligation of Intersphincteric Fistula Tract (LIFT) procedure should be employed. 1, 2

• A history of prior fistulotomy markedly increases the risk of catastrophic incontinence when any subsequent sphincter‑cutting technique is performed. 1

Gender‑Specific Surgical Considerations

• Anterior fistulotomy should never be performed in female patients because the asymmetrical anatomy and relatively short anterior sphincter confer a high risk of compromising continence. 3, 4

Functional Impact of Minor Incontinence

• Even minor continence disturbances can be functionally devastating for individuals who engage in receptive anal intercourse, underscoring the need for aggressive pelvic‑floor rehabilitation. 1, 2