Until recently, imaging had a limited role in the preoperative assessment of perianal fistulas. Magnetic resonance (MR) imaging has been shown to demonstrate accurately the anatomy of the perianal region. In addition to showing the anal sphincter mechanism, MR imaging clearly shows the relationship of fistulas to the pelvic diaphragm (levator plate) and the ischiorectal fossae. This relationship has important implications for surgical management and outcome and has been classified into five MR imaging-based grades. If the ischioanal and ischiorectal fossae are unaffected, disease is likely confined to the sphincter complex (simple intersphincteric fistulization, grade 1 or 2), and outcome following simple surgical management is favorable. Involvement of the ischioanal or ischiorectal fossa by a fistulous track or abscess indicates complex disease related to trans-sphincteric or suprasphincteric disease (grade 3 or 4). Correspondingly more complex surgery may be required that may threaten continence or may require colostomy to allow healing. If the track traverses the levator plate, a translevator fistula (grade 5) is present, and a source of pelvic sepsis should be sought.