Unconventional Insights in the Pathogenesis and Etiology of Fistulas in the Perianal Region

In this chapter we explore a new and different approach for the pathogenesis of a perianal fistula (excluding those coexisting with inflammatory bowel disease) in order to improve the understanding and treatment of this complex disease. We state that the cause of the reported disappointing success rates for the treatment of perianal fistulas might be found in the fact that the approach to this disease is based on one theory that should fit all different clinical features. In doing so we might compare apples and oranges. In clinical practice, we identified a couple of unanswered questions related to the etiology of perianal fistulas. We substantiate our thoughts with basic concepts in histopathology. Continuously, we will focus on the identification of different types of fistula given their different clinical presentation. Further research based on our hypothesis that a different clinical presentation probably is caused by a different etiology might lead to a better understanding and treatment of perianal fistulas.