Anal Fistula Surgery Risks: Recurrence, Incontinence, and the Facts

In my pre-operative consultations for fistula surgery, two questions always come up. The first is "will it come back?" The second — often asked a little sheepishly — is "will I lose control of gas or stool?" Both are entirely legitimate questions, and the answer to each is directly tied to the technique used on you. Let me walk you through the risks honestly, without embellishment.

Recurrence: why does a fistula come back?

This is the age-old issue in fistula surgery. There are three main causes of recurrence: failure to fully close the internal opening of the tunnel, a missed side branch, and re-inflammation of the area during healing. Recurrence rates are fairly low in simple, single-tract fistulas, but rise significantly in branched fistulas, previously operated ones, or those with a Crohn's disease background. So the honest answer to "does fistula surgery come back?" is: it depends on your type of fistula. This is exactly why we place so much importance on accurately mapping the tunnel beforehand — with MRI if needed.

Let me be clear about one thing: recurrence usually does not mean "the surgery was done badly." A fistula is, by its nature, a disease prone to recurrence; good surgery reduces this likelihood, it does not eliminate it. If you come across anyone who promises otherwise, be cautious.

How justified is the fear of gas and stool incontinence?

This fear has a real basis, but it is less relevant today. Some classical techniques require cutting a portion of the muscle that keeps the anus closed while opening the tunnel. In superficial fistulas, this cut usually causes no noticeable problem; but in fistulas that deeply involve the muscle, the risk of gas or wet incontinence is something to take seriously.

This is exactly why modern proctology has shifted toward techniques that never cut the muscle. Techniques like laser (FiLaC) and LIFT close the tunnel without cutting the muscle, largely eliminating the risk of incontinence. That's why, in every suitable case at my clinic, I discuss muscle-sparing options first.

Other risks: short and clear

Bleeding is usually just oozing and stops on its own. Infection sounds plausible since we're working in an already inflamed area, but it's rare with regular sitz baths and hygiene. Pain occurs in the first few days; after laser treatment, most patients describe it as "soreness" rather than "surgical pain." Difficulty urinating is temporary and resolves on the first day. Delayed wound healing is seen more often with wounds left open in classical techniques — it's managed with a proper dressing routine.

Three things that reduce the risk

First, accurate mapping: any procedure performed without knowing the course of the tunnel is open to surprises. Second, choosing the right technique for the right patient: not every fistula suits laser, and not every fistula needs classical surgery. Third, your own contribution: following recovery period recommendations, not skipping check-ups, and staying clear of constipation. Surgery ends on the table, but healing is won at home.

Frequently asked questions

If I experience incontinence after surgery, is it permanent?

Mild difficulty controlling gas in the early period is mostly related to swelling and resolves within weeks. A permanent problem is rare with today's muscle-sparing techniques; your risk should be discussed openly with you before the procedure, based on how deep your fistula is.

If it recurs, is another surgery possible?

Yes. A recurrent fistula is reassessed — usually with MRI — and a second procedure is planned. Recurrence is not a dead end; it's a situation that calls for remapping.

Doesn't laser have any complications?

No procedure is without risk; recurrence is possible with laser too. Laser's real advantage is that it doesn't cut the muscle, meaning it nearly eliminates the risk of incontinence. Even if recurrence occurs, your options don't shrink.

These risks scared me; what if I don't have surgery at all?

The risks of an untreated fistula — branching, recurring abscesses, increasingly difficult surgery — are more lasting than the risks of the operation. I covered this in a separate article.

A clear risk picture for your own fistula only emerges after an examination and, if necessary, an MRI. Let's clarify this together at our clinic in Levent: 444 8 623.

References

• American Society of Colon and Rectal Surgeons (ASCRS) — Clinical Practice Guideline for Anorectal Abscess and Fistula, fascrs.org
• Turkish Society of Colon and Rectal Surgery, tkrcd.org.tr