Conservative versus operative management of perianal abscess and fistula-in-ano in infants: a narrative review

Background and Objective: Infant perianal abscess (PA) and fistula-in-ano (FIA) are a relatively rare clinical entity for which optimal management continues to be highly variable and debated by physicians. This review seeks to describe the current literature on the pathogenesis, clinical presentation, and management of PA and FIA. Methods: The current literature was queried utilizing publicly available free databases including the National Institute of Health Library of Medicine MEDLINE, PubMed, Embase, and Cochrane Library for manuscripts published from 1948 to 2025 using MeSH search terms associated with PA and FIA in infants. Resultant articles were screened for relevance, summarized, and compiled into a narrative. Retrospective cohort studies were compared and bias assessed using the Newcastle-Owatta Score. Key Content and Findings: Infant PA and FIA exhibit a male predominance. Proposed theories of pathogenesis relate to abnormal anal crypt development, hormonal influence, and infant-specific risk factors. Optimal clinical management continues to be debated with some studies advocating for initial conservative management while others suggesting early surgical management is superior. Ten comparative retrospective studies were appraised and found to have differing conclusions on superiority. Notably these studies differed in their studied population and their definitions of conservative management. Conclusions: The current data is limited in its ability to definitively determine the superiority of conservative versus operative management and further hampered by the lack of a standard definition of conservative management. Consensus definitions and quality prospective trials are needed to fully understand this clinical entity. Nonetheless, the current literature suggests a trial of conservative management can be safe and effective.