Concomitant anal fistulotomy (F) and incision and drainage (I&D) of ischiorectal abscesses (IA) are often avoided, for fear of irreversibly impairing anal continence. However, failure to identify and treat the frequently associated trans-sphincteric anal fistula dooms the patient to recurrent anal suppurative disease. We have employed an aggressive approach of performing I&D and F for IA at the time of initial presentation. Adequate drainage is assured by placement of counterincisions and Penrose drains to minimize the time for healing of the perianal wound. Drainage is followed by a careful examination of the anal canal for fistula localization followed by fistulotomy, or less frequently by cutting seton placement. We present our experience with this approach to IA, with special attention paid to the evaluation of recurrence rates and anal continence. This paper represents a retrospective review of 80 patients with IA managed from 1983 to 1996. Operative records and office records were reviewed, and follow-up data were obtained by telephone interview. Internal fistulous openings were identified in 55 (68.8%) patients. Surgeries included: 38 (47.5%) I&D and F, 8 (10%) I&D and seton, and 34 (42.5%) I&D alone. Follow-up data were available on 99 per cent of patients; mean, 44.3 months. Results showed a 44 per cent recurrence rate in those who underwent I&D as compared with 21.1 per cent following I&D and F. 11.8 per cent of patients treated with I&D experienced a change in their level of continence postoperatively as compared to 15.8 per cent treated with I&D and F. The results indicate that an aggressive approach to IA allows identification of a trans-sphincteric fistula in 57.5 per cent of patients with IA. Therefore, optimal surgical management for IA appears to be I&D and F, resulting in a lower recurrence rate and comparable morbidity as compared to I&D alone.