Aim. To evaluate the diagnostic significance of structural changes in the anal sphincter (AS) in patients with complex rectal fistulas (CRF).Materials and Methods. This study analyzed the results of examination and surgical treatment of 87 patients with rectal fistulas. Following a comprehensive assessment, the structural changes in the anal sphincter (SCAS) among patients with complex rectal fistulas were classified into several categories. The first subgroup included 16 patients (18.4%) with complex rectal fistulas accompanied by inflammatory infiltration of the anal sphincter (reactive sphincteritis, RS). The second subgroup consisted of 24 patients (27.6%) who exhibited fibrotic changes in the anal sphincter (anal sphincter pectenosis, ASP). The third subgroup comprised 17 patients (19.5%) with complex rectal fistulas and defects (diastasis of AS muscles) in the anal sphincter fibers. The fourth subgroup served as the comparison group, consisting of 30 patients (34.5%) with complex rectal fistulas but without organic changes in the AS.Results and Discussion. The primary complaint among all patients with complex rectal fistulas was the presence of a fistula opening with purulent discharge, although additional symptoms varied depending on the type of structural changes in the AS. The study demonstrated that ultrasound showed a sensitivity of 87%, specificity of 69%, and overall accuracy of 92% in diagnosing rectal fistulas, consistent with data reported by other researchers. On ultrasound, reactive sphincteritis presented as a homogeneous or heterogeneous structure of anal sphincter fibers with varying shapes and sizes, characterized by hyperechogenicity intimately adjacent to fluid accumulations (or intersphincteric localization), filled with contents of varying degrees of echogenicity depending on the stage of inflammation. The ultrasound characteristics of anal sphincter pectenosis (ASP) differed from RS, showing a decrease in sphincter fiber volume and deformation of the AS with retraction of the muscular ring. Defects in the internal sphincter were characterized by varying degrees of hypoechogenicity, with lengths ranging from 0.3 to 1.2 cm, and were more frequently observed along the posterior rectal wall.Conclusions. Complex rectal fistulas are often associated with organic changes in the structure of the anal sphincter, manifesting as reactive sphincteritis, anal sphincter pectenosis, and defects in the muscle fibers of the external anal sphincter. The clinical course of the disease in patients with ASP is influenced by both the type of rectal fistula and the nature and severity of SCAS.