Surgery & Complications
Perianal Crohn's disease affects roughly one in four to one in three people living with Crohn's, yet it remains one of the least discussed aspects of the condition. The symptoms, which include fistulas, abscesses, fissures, and skin tags around the anus, are painful, disruptive, and often carry a layer of embarrassment that makes them hard to bring up even with a gastroenterologist. Understanding what each manifestation looks like, how they differ, and what treatments are available can make it easier to advocate for yourself at appointments and get the care you need.
What Perianal Crohn's Disease Looks Like
Perianal Crohn's disease is an umbrella term for several distinct problems that develop in and around the anal canal. Some are caused directly by the inflammatory process of Crohn's, while others develop as secondary complications. The four most common manifestations each feel different, progress differently, and require different approaches to treatment.
Fistulas are abnormal tunnels that form between the anal canal and the skin near the anus. They develop when deep ulceration from Crohn's inflammation burrows through tissue and creates a new pathway. The hallmark symptom is persistent drainage, which can include pus, blood, or stool leaking from an opening near the anus. Many people describe needing to wear a pad throughout the day. Fistulas are classified as simple, meaning a single tunnel with one external opening and no abscess, or complex, meaning multiple openings, involvement of significant muscle, or an associated abscess or stricture.
Abscesses are walled-off collections of pus that form when a fistula tract or deep tissue becomes infected. They cause acute, throbbing pain that worsens with sitting or movement, along with swelling, redness, and sometimes fever. Abscesses require urgent surgical drainage and cannot be treated with antibiotics alone.
Fissures are tears in the lining of the anal canal. In Crohn's, these tears often appear in unusual locations, off the midline, which can help distinguish them from common fissures caused by constipation. Crohn's-related fissures are frequently painless and heal on their own in more than 80% of cases, though some become chronic.
Skin tags in Crohn's disease differ from the small, soft skin tags that many people develop with age. Crohn's-related perianal skin tags are often large, firm, and sometimes swollen, sometimes called "elephant ears." They typically develop as a result of prior inflammation or healed fissures. While they are rarely symptomatic on their own, they can make hygiene difficult and cause discomfort.
How Perianal Disease Changes Your Treatment Plan
The presence of perianal disease often accelerates treatment decisions. Guidelines from the American Gastroenterological Association recommend biologic therapy, specifically anti-TNF agents like infliximab, as a first-line medical approach for active perianal fistulas, typically combined with antibiotics such as metronidazole or ciprofloxacin. This means patients with perianal Crohn's may start biologics earlier than those with luminal disease alone.
The treatment pathway generally follows a combined medical and surgical approach. If an abscess is present, surgical drainage comes first. A colorectal surgeon may place a seton, a thin piece of surgical thread passed through the fistula tract and looped out through the skin, to keep the tract open, prevent further abscess formation, and allow ongoing drainage while medical therapy works to reduce inflammation. Once infection and inflammation are well controlled, definitive surgical options become available. These are sphincter-preserving procedures designed to close the fistula while protecting continence, including fistulotomy, advancement flap repair, and a technique called LIFT (Ligation of the Intersphincteric Fistula Tract).
Newer biologics, including vedolizumab, ustekinumab, and risankizumab, have also shown effectiveness for perianal fistulas when anti-TNF therapy has not worked. Anti-TNF agents achieve fistula remission in roughly 35 to 40% of patients at one year, which means many people require adjustments to their treatment plan over time.
Practical Day-to-Day Management
Living with perianal Crohn's means managing symptoms between appointments. A few consistent habits can reduce irritation and help you stay more comfortable.
Warm sitz baths, sitting in a few inches of warm water for 10 to 15 minutes, can provide meaningful pain relief for fissures and post-surgical healing. A handheld showerhead, bidet, or squeeze bottle is gentler than toilet paper for cleaning, and switching to a moist towel can further reduce irritation. Barrier creams such as zinc oxide or Vitamin A&D ointment applied before bed protect the skin from ongoing drainage. Loose-fitting clothing and unscented products help avoid additional irritation.
Tracking your symptoms, including drainage frequency, pain levels, and swelling, gives your GI team concrete information to assess whether your current treatment is working. This is especially valuable for perianal disease, where changes can be subtle and hard to describe in a short appointment. Aidy can help you log these symptoms consistently so your care team has the data they need to catch recurrence early and adjust your plan.