Aim: Perianal Mycobacterium tuberculosis is rare, but tuberculosis (TB) is now endemic in many areas of the world. It is essential to recognize TB to institute appropriate management. We report three cases of TB presenting with supralevator abscess. Method: We analysed the outcomes of three patients who presented to our unit, from 2004 to 2009, with supralevator abscess caused by TB. Results The patients presented as emergencies with symptoms of per-anal sepsis. All required multiple drainage procedures. Supralevator extension was confirmed clinically and radiologically (by magnetic resonance imaging in two patients and by computed tomography scanning in one patient). One patient was diagnosed by perianal biopsy, the second by culture of pus and the third by sputum culture. Following drainage, all three patients were given anti-TB medication for 6months. In all patients, the fistulae had high communication with the anal canal. In one patient, local drainage and medical therapy led to sepsis resolution, the second patient has residual complex fistulae and the third patient has recently commenced antimicrobial therapy. Conclusion As TB is endemic in many parts of Europe, TB should be suspected in patients with complex and/or recurrent perianal sepsis. Samples for histological and bacteriological analyses should be obtained from these patients. Recurrent perianal drainage procedures are likely to be required, and sepsis may persist after anti-TB therapy. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.