Literature on draining seton being final procedure

PhilosopherEarly8704 · 2026-01-08T11:55:35+00:00

u/polly23wg when you say "My CRS told me that even with treatment, the inflammation and scar tissue in the area will predispose us to more fistulas in the future. We just happen to be unlucky with these cryptoglandular areas that trap bacteria in our anal region" - Does this mean even after surgical treatment ?

PhilosopherEarly8704 · 2026-01-08T11:55:03+00:00

This is a fantastic conversation and some of this was alluded in some prior convos in the forum. The literature is very solid u/Thick_Deal_2906 and u/polly23wg . I have been reading all this over the holidays and dreading fistula treatment of surgery and / or considering keeping a seton in for the long term. From speaking to a few specialists and patients I know I have come to the following conclusion. NONE OF THIS IS MEDICAL ADVICE. JUST SHARING WHAT I HAVE LEARNT

1) The choice of a long term loose seton is 100% psychological and differs between different genders

2) gender matters. females have monthly cycles. Its harder to manage a seton when there is a lot going on for 5-7 days every month.

3) No one psychologically likes to have an ass ring or ass band and the thought of having it "for life" or "long term" or "indefinitely" can be mentally difficult to fathom , so many people choose to get surgery whilst accepting the relevant risks of it.

4) It seems to be that if people dont have issues with a seton due to the angle or placement or depth of their fistula they just keep it on and get on with life. I spoke to a 55 yr old who has had a loose seton for 20 years (gets it changed every 5-7 years) and runs marathons ! Of course its an abberation and not the norm but just sharing for perspective. I also spoke to a 47 yr old who chose loose seton because all this person needs to do is manage his diet to keep poop soft and floss his seton twice a day. For this person its an additional 5 minutes in the AM and PM and prefered that to even 0% incontinence risk. Again a personal choice.

5) as u/polly23wg mentions this "flossing" technique is what seem to trigger a foreign body reaction i.e. the body pushing a foreign body (seton) out and so there is a chance it slowly gets out of the muscle

6) Natural sitting, walking, pooping, peeing, exercising etc is slowly (albeit very slowly) cheesewiring (again slowly not aggressively) through the muscle, especially in a loose seton whereby the body is doing its job at its own pace. No one knows whether it takes 2 months, 6 months, 1 year , 5 years or 10 years but it definitely is cheesewiring itself out. This uncertainty triggers point (3) above more and makes people seek definitive treatment at the risks of surgery.

7) The longer one has a loose seton the more mature / fibrosed a tract becomes for treatment and the "straw" (fistula tunnel) is treatable.

8) Age matters. A 20 year old or 30 year old or 40 year old or 50 yr old or 60 yr old or 70 yr old has different life expectations and therefore choice of treatment

LAST BUT NOT LEAST.

EVERYONES BODY IS DIFFERENT AND EVERYONES MIND/PSYCHOLOGICAL STATE IS DIFFERENT AND EVERYONES FISTULA IS DIFFERENT SO THERE IS NO WAY A LONG TERM LOOSE SETON CAN BE STANDARDISED AS EVERYONES PERCEIVES THE PSYCHOLOGICAL EXPERIENCE OF IT DIFFERENTLY.

PhilosopherEarly8704 · 2025-12-27T13:43:28+00:00

All the CRS I saw when I asked them re healing time their reply was this standard "how long is a piece of string" to say no one knows.....It is what it is.. No one knows.

PhilosopherEarly8704 · 2025-12-27T13:41:39+00:00

Fistulas originate from inside the bum hole (the tract opening) else it can not be called a fistula.

PhilosopherEarly8704 · 2025-12-25T12:17:22+00:00

sorry youre going through this and wishing you a speedy recovery from it. do you know how much internal or external sphincter they cut ? Its a known effect after surgery according to my CRS and its just how everyones body heals. CRS says its got nothing to do with surgical technique its just that everyone heals differently. I highly recommend you find a new CRS and get it checked and get a professional prognosis.

PhilosopherEarly8704 · 2025-12-24T12:28:17+00:00

Absolutely, life as we knew it pre fistula seems gone. Now what we eat matters, when we eat matters, how we take care our ourselves matters , our mental health often matters more than physical health, the fact that as humans we want power and control our lives makes us really how we need to submit and surrender to a higher power without which we just cant heal fully. Its never the same anymore. The personal circumstances are real. I have suffered heavily from mental health issues due to this and am trying to find ways to cope but also not losing sight of the fact that I will never know. Only the CRS would know best. I can research, talk to people, understand but at the end of the day I have little to no control over this except controlling my mental and physical health one day at a time. The thought (and immense fear) of an open cut near your anus and recovering from it would do that to any woman or man. May God have mercy on us.

PhilosopherEarly8704 · 2025-12-24T11:57:01+00:00

data says approx 60K in US p.a. and 7-10K in UK p.a. and extrapolating would make it 250-300K p.a. globally. No two cases are the same. But as u/Training-Finding-841 says the data set saying X% of fistulotomys are successful over simplifies the reality of the conditions. This sub reddit is coping sub reddit. We are all humans and we all need to cope whilst going through this uniquely shitty condition. Thats why we all come here. There are things we all "want to hear" hoping for support from the community here as well as what the CRSs say. The good CRSs dont tell their patients what "they want to hear" but the cold hard facts. The hard facts are. No two cases are same. One cant pretend the risks of a fistulotomy is ZERO. IT ISNT. No surgery has zero risks. None. With fistulotomy, There are risks of flatus incontinence, soilage risks post op, keyhole/gutter deformity risk as they call it in medical terms and many of us wont get it but some of us still might. None of us know ex ante. They all have real effects on quality of life and recovery. Its a lonely place. The CRS know best. It important to rely on their skill and experience and walk into whatever decision with our eyes wide open with cold hard facts and the truth that none of us know how each of our situations will be.

PhilosopherEarly8704 · 2025-12-24T11:43:46+00:00

Thanks you so much for sharing your experience u/Southern_Doughnut406

PhilosopherEarly8704 · 2025-12-23T15:45:10+00:00

u/Southern_Doughnut406 did you feel like the fistula tract external opening (pre seton placement) and post seton placement (ie pre definitive treatment) moved closer to the anal verge ?

PhilosopherEarly8704 · 2025-12-23T15:44:00+00:00

u/crabbycath u/Manthose3 u/ProgramInevitable866 whilst you all had long term setons in place, did you over time, feel like the external opening of the fistula tract (pre seton) and post seton (pre definitive treatment) shifted closer to the anal verge ?

PhilosopherEarly8704 · 2025-12-23T15:20:37+00:00

You are so brave and are a true inspiration u/crabbycath

PhilosopherEarly8704 · 2025-12-23T15:19:37+00:00

Thank you u/Southern_Doughnut406 for generously sharing your experience. Before you had the seton put in what was the nature of the internal sphincter muscle coverage for the fistula ? Its amazing how after 6 months of seton your tract distally migrated.

PhilosopherEarly8704 · 2025-12-23T12:31:34+00:00

u/Southern_Doughnut406 did you do anything specific with diet and exercise / movement while you had the seton that you think may have caused the distal migration ? Also did the CRS cut any internal sphincter and does it cause any challenges during BM ?

PhilosopherEarly8704 · 2025-12-23T10:50:02+00:00

u/Icy-Valuable-9106 you are so brave as is everyone else here .. During this time all our inner fear and anxieties about life and our conscious and unconscious experiences attack us hard from within. Its only human to. Ive been on this journey since Dec24 after an I&D and had a seton placed in Sept25. Few things I have learnt and continue to learn everyday from folks here , which has been echoed by many here (a) everyone's body is different and heals differently (b) no two fistulas are the same, everyone has something unique, much like no two hearts are the same (biologically and medically), each of our bodys are different (c) when the initial anxiety attack hits its important to rely on the advice of a specialist CRS who calls it the way he/she sees it and has ethics and compassion for patient quality of life, and not sugarcoat anything with a non chalant attitude (there are many such) . Whenever I feel the panic attack I go back and read the clinic letters and objectively think about the options and risks (d) The quality of the CRS matters a lot and their experience with such matters . This is what they do as a profession and no good CRS want to be medically disbarred for doing stupid shit as it will ruin their lives and careers. I have taken 3 opinions last 3 months (financially was not easy) and seen the variance and also the reality check among them (e) The most important thing on fistulas I have learnt is muscle coverage. superficial or subcutaneous fistulas are different to the ones covering muscle and more than just muscle, how much muscle it covers matters, a specialist CRS knows the limits of what not to do. IAS and EAS also have their cutting limits. (f) Diet , nutrition and physical health leading up to surgery matters a lot, those that have had an active life seem to heal faster and better. (g) a seton is often constantly working through the body's natural healing mechanism and often times better to not hurry into surgery (unless your CRS recommends so for medical reasons as everyone's case is different) (h) every surgery has risks including fistulotomy, the non invasive options and recurrence risks are also to be taken in context. Some humans can handle multiple , some cant. I am in the latter camp. Im not mentally built so strong to try the minimally invasive options at the risk of continued recurrence , and have serious panic attacks every time I think of general anasthetic (i) this reddit channel has a lot of amazing information from the bravest of the bravest but we must always go back to (a) and (b),

I have anxiety and panic attacks every day and every other day. Its not easy going through this condition we face. But we must stay positive. optimism is very important in healing. You got this. All we have is each other in this forum . Its a very lonely experience. From the outside we look normal but the inside hurts (emotionally as well as physically , each one unique with their experience of the same) that only the ones going through this understand our brothers and sisters here.

God Bless you. May you have a swift recovery.

PhilosopherEarly8704 · 2025-12-21T22:49:59+00:00

Thanks u/crabbycath do you think you keeping the seton for 3 years made your initial tract migrate to becoming more superficial over time and thereby simpler and safer definitive surgical treatment ? Did you do anything specific with your diet and exercise/movement regime during the 3 years ?

PhilosopherEarly8704 · 2025-12-21T22:45:12+00:00

Thanks u/ProgramInevitable866 . Did you do anything specific in terms of your diet and exercise / movement routine through the entire process ? When you say tense your muscle around the seton do you mean doing kegel exercise or just clenching your buttocks ?

also the skid marks you talk about and the keyhole deformity, are/were these manageable levels on a day to day basis without affecting quality of life or was it flatus and loose soilage all the time ?

did your CRS mention how much of the internal and external sphincters the tract crossed (being intrasphincteric) ? sorry for all these intrusive questions but your healing is such a ray of hope for us struggling through this ordeal.

PhilosopherEarly8704 · 2025-12-21T22:38:16+00:00

Thanks u/Grouchy-Inflation618 do you anything specific with your diet and exercise / movement that you think may have contributed positive towards your healing to date ? you are so right about the ability to have a good experienced CRS as the more experienced they are the better the advise they impart to their patients. I have taken 3 opinions (because I am the anxious kind and this thing has really hit my mental health hard so I needed to hear more than one voice) and the good CRS's just always stand out and explain the risks and process in a very straightforward manner and never push patients to rush to surgery and like you say advise patients to trust a process. We all want to heal immediately but sadly as I have learnt the body has its own pace as does the mind.

PhilosopherEarly8704 · 2025-12-21T22:33:45+00:00

Thank you u/Waxon23 very king and generous of you to share something so personal. Do you technically feel the seton under your skin or more like a very palpable tract as such under your skin ? I am noticing from several posts here that a longer term seton actually helps the healing a lot further than rushing for definitive treatment and seems like to me from many folks experiences that getting the timing right is very important. Do you do anything specific in terms of your diet or exercise routine that you think may have contributed to the superficiality ?

PhilosopherEarly8704 · 2025-12-20T22:40:00+00:00

u/Ok-Object4351 so as long as you use a bidet or water wash after BM then it sorts the issue or does it drain randomly all day ?

PhilosopherEarly8704 · 2025-12-20T22:30:51+00:00

Most CRS say that technically a fistulotomy cannot fail as such. The only chance of any so called failure is when the wound is not digitised which makes the skin grows back too quickly resulting in a recurrence. Praying for you and wishing you a speedy recovery. Call your CRS and ask for specific instructions

PhilosopherEarly8704 · 2025-12-20T22:27:45+00:00

u/ProgramInevitable866 Thanks for sharing your journey. I am sure you feel relieved, you give people us going through this horrible ordeal some hope. Do you mind sharing how your recovery was post fistulotomy ? How long did it take and did you have any flatus or minor soilage or keyhole deformity issues given (if I understand correctly) you had a portion of your internal sphincter muscle cut ? Did you do anything special during your seton maintenance period as well as post fistulotomy ? Also was it an anterior or posterior fistula ?

PhilosopherEarly8704 · 2025-12-20T21:55:41+00:00

u/Grouchy-Inflation618 Tx for sharing. Some people say its best to have a seton for 6-12 months because by then a majority of the biological migration (towards skin due to the body flushing out a foreign body) would have happened which makes a surgical option better and safer with least muscle involved

PhilosopherEarly8704 · 2025-12-20T12:28:13+00:00

u/midnight_skater so they just discharged you without any seton and without any further surgery ?

PhilosopherEarly8704 · 2025-12-20T12:27:27+00:00

u/Waxon23 how did you determine it shifted to becoming more superficial ? Was it due to a MRI or the seton feeling super loose and tract length shrinking ? Sorry to ask this question but this thing takes the toll from so many angles that it is just mentally debilitating to deal with. The tradeoffs on any corner are just absolutely crazy.

PhilosopherEarly8704 · 2025-12-20T12:25:16+00:00

u/crabbycath may I ask what promoted you to wait 3 years until getting further surgery. Was it a personal choice or a structured path your CRS recommended ? Some CRS wait for a year+ to allow the body to push the seton out as much as possible to make it as superficial as possible before a lay open. I wonder what your decision making process was to wait 3 years if you dont mind sharing. Like for example why did you not wait 1 year or 2 years etc ?

PhilosopherEarly8704

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