Snapshot A 39-year-old man with inflammatory bowel disease presents to his primary care physician due to concern of anal discharge. He reports that he has been compliant with his inflammatory bowel disease medications and has an upcoming appointment with a surgeon for drainage of a perianal abscess. On exam, an abnormal communication to the perianal skin is visualized. Introduction Clinical definition pathological tract lined with granulation tissue between the anal canal and perianal skin (usually within 3 cm of the anal margin) demographics more common in men risk factors anal abscess Associated conditions Crohn disease diverticulitis human immunodeficiency virus etiology Pathogenesis infection of the anal gland and abscess development that tracts to the skin surface inappropriate wound healing leading to persistent tract (FRIENDS mnemonic) foreign body radiation therapy inflammation or infection epithelization neoplasm distal obstruction steroids Presentation Symptoms perianal drainage tenderness or pain bleeding itching Physical exam perianal fistula with induration, erythema, purulence, and fecal discharge elevated skin with underlying granulation tissue Studies Diagnostic testing direct visualization of the fistula with anoscopy or proctoscopy is diagnostic probe fistula to identify both openings under anesthesia, if necessary Differential Pilonidal cyst distinguishing factor does not communicate with anal canal Hidradenitis suppurativa distinguishing factor does not communicate with anal canal Treatment Fistulotomy Infliximab for Crohn disease-associated fistula Complications Persistent fistula