Anal fistula and abscess still represent one of the most debated fields in coloproctology. The lack of certainty about the etiology of anal fistulas could in part explain the persistence of such controversies on this topic. The most accepted theory dates back to 1961 and considers the infection of a gland of the anal canal as the main cause of anal fistulas. Since then, no other major advances have been made in the etiopathogenesis of this disease. However, some more recent evidence suggest that further factors (including chronic inflammation and other immunological aspects) could contribute to the development and persistence of anal fistula. Although still controversial, the diagnostic assessment of the disease is fundamental to modulate the abscess and fistula management, with the peculiar aim to obtain the anal fistula healing while avoiding severe and disappointing sequelae following the treatment. This aspect is particularly true when the impact of the traditional surgical options on the anorectal physiology is considered. Their use should be adopted with caution, preferring to prevent extensive sphincter damage and/or to immediately repair iatrogenic lesions. On the other hand, the more recent introduction of several alternative options in clinical practice, aimed to preserve sphincter structure and function, has improved the opportunity to provide a “sphincter-saving ” surgical operation. In this regard, modern technologies have attempted to significantly contribute to their therapeutic efficacy. However, to date, the controversies in the results obtained do not allow to establish their position in the algorithm of treatment of anal fistulas.