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Purpose: Evidence is lacking whether an abscess associated with anastomotic leak after ileal pouch-anal anastomosis should be drained by transanal or CT guided drainage. In order to clarify their relative potential implications on subsequent anastomotic healing, development of extrasphincteric fistulae and long term pouch retention, we compare outcomes after the two techniques for drainage. Methods: Patients who underwent IPAA from 1984-2009 and diagnosed with a pelvic abscess associated with an anastomotic leak on imaging studies were identified. Choice of operative or image-guided drainage was based on surgeon preference. Differences between patients undergoing transanal (Group A) and CT-guided drainage (Group B), for demographic, preoperative, and operative details, functional outcomes, and quality of life were determined. Results: Group A (n=56 ) and group B (n=19) had similar age (32.3 ±13.9 vs.29.6 ±12.2 years,, p=0.53), gender (male:75% vs. 70%, p=0.67), BMI (27.4 ±6.6 vs. 27.9 ±4.5 kg/m2, p=0.31), diagnosis (ulcerative colitis, 64.7% vs. 63.2%, p=0.15), steroid use (51% vs. 57.9%, p=0.61), albumin level (4.1 ±0.6 vs. 4.3 ±0.2 g/dl, p=0.28), defunctioning ileostomy (92.3% vs. 85%, p=0.39), length of hospital stay (days, 9.4 ± 5.3 vs. 13.9 ± 12.1) and follow up time (5.2 ±4.6 vs. 4.3 ±4.8 years,, p=0.48). Size of abscess was greater in Group B (5.3±2.6 vs. 8.5±3.4 cm, p=0.007). Site of CT-guided drainage was mainly gluteal (n=12). Two patients (10.5%) developed fistula at CT-guided drainage site. Both healed after conservative treatment and drainage of associated gluteal abscess, respectively. Seven patients (12.5%) in group A and 4 patients (21%) in Group B (p=0.4) had pouch failure and underwent redo pouch surgery, pouch excision or permanent diversion despite drainage of the abscess. At most recent follow-up, Groups A and B had similar bowel frequency (p=0.57), incontinence rate (p=0.46), urgency (7.9% vs. 15.4%, p=0.46), seepage (p=0.39) and pad usage (p=0.92). Quality of life (p=0.6), happiness with surgery (p=0.34), dietary (p=0.32), social (p=0.91), sexual (p=0.62), and work restrictions (p=0.92) were also similar. Conclusion: There is a risk of development of a fistula at the site of CT guided drainage of pelvic abscess associated with anastomotic leak following IPAA. Transanal and CT-guided drainage however result in similar long-term outcomes.