Anorectal Abscess

An anorectal abscess can lead to severe pain and disability in patients. Abscesses occur most often in the third or fourth decade of life and in a 3:1 to 2:1 male/female ratio (Hebra, 2009). An anorectal abscess develops from an infection originating in the anal glands and crypts at the level of the dentate line and tracking along the lines of least resistance. This tracking results in up to 50% of abscesses being associated with simultaneous fistula development. Locations of the abscess can vary and may be located in the perianal area (60%), ischiorectal area (20%), intersphincter region (5%), supralevator region (4%), and submucosal location (1%) (Fig. 28-17). Abscesses can result from other anorectal infections or pathology such as Crohn's disease fistulas, adenocarcinoma, trauma, immunosuppression, and sexually transmitted diseases. A thorough anorectal examination, frequently under anesthesia, is required for complete evaluation. Most abscesses can be localized by physical examination. Deep or large abscesses require a pelvic CT scan to determine the extent of tracking and to plan surgical intervention.

An anorectal abscess should be treated by incision and drainage. The lack of fluctuance should not delay a timely drainage procedure. Antibiotics are an unnecessary addition to routine incision and drainage of uncomplicated perianal abscesses (Whiteford et al., 2005). No conclusive evidence exists for a simple drainage versus sphincter-cutting procedure in the treatment of anorectal abscess (Quah et al., 2006). Antibiotics should be considered only as an adjunct to drainage in patients with immunosuppression, diabetes, prosthetic devices, or significant systemic illness.

Before surgical decompression, an anoscopy should be performed to identify a potential internal draining fistula source at the dentate line. Injecting an agent over or under the mass can provide local anesthesia, although rarely patients may need spinal or general anesthesia. Incision and drainage of superficial abscesses can be accomplished with use of an 11 blade over the area of maximal fluctuance or swelling in a radial orientation. Loculations can be broken by probing with a forceps or gloved finger. A Penrose drain or gauze packing can be placed for continued drainage with appropriate follow up in 1 to 2 days. Recurrent abscesses can occur when there is an unrecognized and untreated underlying fistula. A fistulotomy must be performed in these cases.

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