At a glance
Fistula recurrence is a known possibility after any fistula procedure. While most fistula treatments have good success rates, a proportion of fistulas do come back. Understanding why this happens, what the risk factors are, and what can be done about it helps people navigate this challenging situation.
Why fistulas recur
Unidentified tracts
One of the most common reasons for recurrence is a secondary fistula tract that was not identified or treated during the original surgery. Fistulas can have multiple branches, and if one is missed, it can serve as the source for recurrence.
Incomplete healing
If the fistula tract does not fully close during healing — which can happen if the wound closes at the surface before the deeper tract has healed — the residual tract can become reinfected and reopen.
Underlying conditions
Crohn’s disease and other inflammatory conditions create ongoing inflammation that drives fistula formation. Treating the fistula without controlling the underlying disease often leads to recurrence.
Complex anatomy
Some fistulas are inherently complex — multiple tracts, horseshoe extensions, or involvement of significant sphincter muscle. These are harder to treat definitively and have higher recurrence rates.
Infection
Post-operative infection at the surgical site can disrupt healing and lead to recurrence.
Risk factors
Factors associated with higher recurrence risk:
- Complex fistula anatomy (multiple tracts, horseshoe)
- Crohn’s disease or other IBD
- Previous fistula recurrence (recurrence risk increases with each episode)
- Incomplete drainage of abscess before definitive surgery
- Certain surgical techniques — sphincter-preserving procedures generally have higher recurrence rates than fistulotomy, as a trade-off for protecting continence
What to do if it recurs
Do not assume the worst
Recurrence is frustrating and disheartening, but it is manageable. The fact that it came back does not mean it cannot be treated.
See your surgical team
Contact your surgeon or colorectal team. They will typically:
- Examine the area
- Arrange updated imaging (MRI) to map the current fistula anatomy
- Assess whether the recurrence is in the same location or a new tract
- Discuss treatment options
Treatment options for recurrent fistula
- Seton placement — to control drainage and allow inflammation to settle
- Repeat fistulotomy — if the anatomy allows
- LIFT procedure — for transsphincteric recurrences
- Advancement flap — for complex recurrences
- Medical management — particularly for Crohn’s-related recurrences
- Newer techniques — VAAFT, fistula plug, and other evolving approaches
The choice depends on the anatomy, what was done previously, and the surgeon’s assessment.
The emotional dimension
Fistula recurrence is one of the most emotionally difficult experiences in colorectal care. People describe:
- Devastation when symptoms return after months of healing
- Anger at the condition and the process
- Fatigue from the prospect of more surgery and more recovery
- Fear that it will keep coming back
These feelings are valid and understandable. Recurrence does not mean the first treatment was wrong or that the situation is hopeless. It means the fistula is complex, and complex problems sometimes need more than one intervention.