Perirectal Abscess


Article Author:
Steven Turner


Article Editor:
Jasvinder Singh


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
7/15/2019 10:57:45 PM

Introduction

The anorectal abscess can vary on the spectrum of complexity based on the location and involvement of surrounding tissue. A thorough understanding of the anatomical structures and their relationship to each other is important for both accurate diagnoses of the disease and to provide appropriate treatment to avoid the complications of multiple procedures and increased costs associated with delayed diagnosis.

Etiology

Anorectal abscesses are typically caused by inflammation of the subcutaneous tissue usually from an obstructed crypt gland. The normal anatomy of the anus includes the presence of these glands at the dentate line. Debris overlying these glands are often the infiltrative mechanism by which the bacteria gain access to the underlying tissue and produce infection. As such, infective organisms that can cause this include Escherichia Coli, Staphylococcus aureus, Streptococcus, Enterococcus, Proteus, Prevotella, Peptostreptococcus, Porphyromonas, Fusobacteria, and Bacteroides. Risk factors that that may predispose patients to abscesses include trauma, tobacco abuse, liquid stool entering the duct, and dilated ducts which lead to poor emptying.

About 10% of cases are associated with HIV, Crohn disease, trauma, tuberculosis, STDs, radiation, foreign bodies, and malignancy

Epidemiology

The incidence is 1:10,000, resulting in approximately 68,000 to 96,000 cases in the United States per year with a male prevalence of 3:1 during the third and fourth decades of life. The condition is seen more in the summer and spring months. Although often a concern of the patient, data does not support that there is an increased risk from hygiene, anal-receptive intercourse, diabetes, obesity, race, or altered bowel habits.

Pathophysiology

Although often thought of as the same, perianal abscess and perirectal abscesses differ in both complexity and care options. Except for perianal abscess which can be simply incised and drained as definitive care, all others usually require intravenous antibiotics, surgical evaluation, and drainage. A majority of abscesses are diagnosed clinically based on skin findings and palpitation of the affected area alone, but some require advanced imaging to determine the extent of infiltration. A perirectal abscess can be further divided into a category based on anatomical location: ischiorectal abscess, intersphincteric abscess, and supralevator abscess. Given the variability in location and severity of the abscess, it is important to consider the presence of fistulas or tracts which may contribute to the spread of the infection. Perianal abscesses are the most common type, followed by ischiorectal, and intersphincteric abscesses.

Alternatively, the Park’s classification system which groups the fistulas into 4 types based on the course of the fistula and the relationship to the anal sphincters.

  • Intersphincteric (70%): Between the internal and external sphincters
  • Trans-sphincteric (25%): Extends thru the external sphincter into the ischiorectal fossa
  • Suprasphincteric (5%): Lasses from the rectum to the skin through the levator ani
  • Extrasphincteric (1%): Extends from the intersphincteric plane through the puborectalis

History and Physical

Patients will often present to the emergency department with acute pain in the perianal or perirectal region. Other presenting symptoms include a dull or aching pain with defecation, movement, sitting, or coughing. Supralevator abscesses may be described as lower back pain or a dull ache in the pelvic region. Also, fever, malaise, rectal drainage, redness of surrounding skin, and possible urinary retention may be included in the patient history.

Most physical exams are done in the prone or left lateral decubitus position, revealing erythema, induration, fluctuance, tenderness, and spontaneous drainage. Pertinent physical exam findings, often performed in the Sim position, include erythema of the surrounding skin, superficial or deep mass with tenderness to palpation, tenderness on palpation of the rectum and deep structures, or discharge. A digital rectal exam may aid in the diagnosis, but variability exists among physicians ability to identify the abscess on the exam accurately. Constipation or tenesmus may be present in patients that have significant pain with a bowel movement.

Evaluation

Laboratory abnormalities may include elevated white blood cell count, increased neutrophils, the presence of bands, and elevated lactate levels. Imaging modalities such as endoanal ultrasound, transperineal sonography, computed tomography (CT), and MRI are useful to confirm the diagnosis. CT should be obtained in patients with significant comorbidities, complex suppurative anorectal conditions, and when surgical consultation may not be immediately available. Optimal imaging may require utilizing triple contrast in certain conditions and using 2.5 mm slices. Endoanal ultrasound imaging is best captured by using a 2-dimensional or 3-dimensional probe with a frequency of 5 to 16 MHz.

Treatment / Management

As with all abscess, once identified, the mainstay of treatment is incision and drainage given the significant concern of extension into nearby tissue. Simple, superficial perianal abscess and some ischiorectal abscesses can be drained at the bedside. A horseshoe abscess is a large abscess in the deep postanal space which extends bilaterally to the ischiorectal fossae. This must be treated in the operating room by a specialist. For superficial perianal abscesses, giving the appropriate amount of anesthetic with epinephrine should be sufficient to adequately incise and drain the abscess. Typically, the incision is cruciate or elliptical and made as close as possible to the anal verge to minimize the potential long fistula formation. Given that a large number of abscesses are associated with a fistula, concomitant fistulotomy or seton placement may be performed with varying results. However, compared to an incision and drainage, a fistulotomy is associated with a significantly lower rate of recurrencePacking of the wound is controversial, but Perera et al. did not find significant evidence to support an advantage over packing the wound compared to incision and drainage without packing.

Surgeons should perform an examination under anesthesia to evaluate patients with recurrent or bilateral abscesses for intraoperative drainage, including cases where internal draining may be necessary. A larger abscess may require placement of a drain for up to 3 weeks. Catheters are also recommended for patients with severe systemic illness, underlying comorbidities including diabetes and morbid obesity. The catheters can be placed after a small stab incision is made thru the skin using a mushroom tip catheter 10 to 14 Fr which is then secured to the skin with a suture. Surgeons generally follow up at 2 to 3 weeks for incision and drainage patients, and 7 to 10 days for patients with mushroom tip catheters. They are usually followed until completely healed. High fiber diet is recommended.

Antibiotics are recommended when there is associated cellulitis of the surrounding skin, patients that fail to improve after drainage and immunocompromised patients. Currently, no data exist to suggest that antibiotics will reduce fistula formation. Antibiotics should include coverage for the organisms listed above. We recommend obtaining wound cultures if antibiotics are prescribed, especially those who already have completed a prior course, or known resistance in the past. We recommend treating with amoxicillin-clavulanate or ciprofloxacin plus metronidazole for 10 days.

Differential Diagnosis

Differential diagnosis includes anal fissure, anal fistula, thrombosed hemorrhoid, pilonidal cyst, buttocks abscess, or cellulitis of the skin, Crohn’s disease, ulcerative colitis, malignancy, proctitis, HIV/ AIDS, other sexually transmitted diseases, Bartholin’s abscess, and hidradenitis suppurativa.

Prognosis

Perirectal abscess has very high morbidity. Recurrence and chronic pain may occur in more than 30% of patients. Development of a chronic fistula is very common if the disorder is treated only by incision and drainage. Other complications include urethral irritation, urinary retention, and constipation.

Even with fistulotomy or the use of a Seton, recurrence rates of 1-3% have been reported.

Complications

  • Bacteremia/sepsis
  • Fistula formation
  • Fecal incontinence
  • Urinary retention

Postoperative and Rehabilitation Care

After treatment, the patient needs pain control, laxatives to avoid constipation and instructions on sitz baths.

Outpatient antibiotics may be indicated depending on the culture and sensitivity of the organism.

Because of a high recurrence rate, all patients need to be followed up until there is complete healing, which may take anywhere from 3-8 weeks.

Consultations

Any anorectal abscess that is not easily visible/palpable should be evaluated by a surgeon.

 

Enhancing Healthcare Team Outcomes

Perirectal abscess affects many people in between the third and fourth decade of life. These abscesses are extremely difficult to treat and errors in management can lead to fistula formation. Many patients have repeated visits to the emergency room for urinary retention, pain, fecal incontinence, and chronic constipation- all of which lead to a rise in healthcare costs. Thus, these lesions are best managed by an interprofessional team that includes the following:

  • The emergency department physician to manage the acute pain, urinary retention, and bacteremia
  • The colorectal surgeon who performs the fistulotomy or Seton placement
  • Nurse practitioner to follow the patient in the clinic to ensure complete healing which may take 4-8 weeks. Patients with Crohn disease, radiation injury, HIV, malignancy or trauma may require even longer follow up as healing is delayed. The nurse is also responsible for teaching the patient how to use a sitz bath to maintain perineal hygiene and obtain pain relief
  • Dietitian to educate the patient on a high fiber diet to relieve constipation
  • Infectious disease nurse to educate and monitor the patient on the maintenance of personal hygiene, safe sex practice and remain compliant with antibiotics.

Patients with Crohn disease often require life long monitoring as they have a high recurrence rate.

Outcomes

While the mortality from a perirectal abscess is low, the morbidity is very high. These lesions can cause significant anorectal pain, urinary retention, and fecal incontinence. In addition, the quality of life in patients with recurrence is poor. Most patients with recurrence require multiple hospital admissions for pain management, urinary retention, and constipation. Premature surgery or a simple incision and drainage by a clinician not familiar with this disease can lead to a chronic fistula which can take months or even years to heal. Thus, it is vital that patients with perirectal abscess be managed by an interprofessional team that communicates. Above all, if there is any doubt, a colorectal surgeon should be consulted before performing any type of invasive procedure.


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Perirectal Abscess - Questions

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Which is true about an anorectal abscess?



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Which of the following most commonly presents with a fever, systemic symptoms, and a deep tender mass on palpation of the buttocks or on rectal exam?



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Select the best treatment for a deep perirectal abscess.



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Which of the following is necessary when performing an incision and drainage of a buttocks abscess?



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A 17-year-old male presents to the emergency department with acute pain in the perianal area. He also complains of pain during defecation and sitting. Past 12 hours he has had a low-grade fever, malaise and has difficulty passing urine. Because of the severe pain, the rectal exam is done under mild sedation. The exam reveals erythema, induration, and fluctuance around the anal area. There is also a small amount of drainage when the fluctuant mass is compressed digitally. What is the ideal treatment recommended for this patient?



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A 17-year-old female with Crohn disease presents with anorectal, pain, fever, and malaise for the past 24 hours. Because of the rectal pain, she is placed under general anesthesia and an endoscopic ultrasound probe is used to assess the anal cavity. It is discovered that she has a fluctuant collection in location A but there is no evidence of any fluid discharge. (See image below). What treatment should be offered to her?

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Attributed To: Image courtesy Dr Chaigasame



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A 48-year-old female with past medical history of B cell lymphoma colitis on pembrolizumab presents with bilateral perianal abscesses. Patients states she was here 1 week ago with the same and now increase in pain and erythema. What is the appropriate treatment for this patient?



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After undergoing radiation treatment for an anorectal mass, a 65-year-old male presents with anorectal pain, fever, fecal incontinence, and general malaise. Lately, he has difficulty emptying the bladder for which he has sought treatment in the emergency department. He undergoes a rectal exam under anesthesia which reports that he has developed one of the most common types of fistula with a small collection of fluid. Based on the image shown below, which letter corresponds to his pathology?

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Perirectal Abscess - References

References

Proctitis and perirectal abscesses: is there anything else to think about?, Martín-Lagos Maldonado A,Herrera Mercader MDC,Lozano Cejudo C,, Revista espanola de enfermedades digestivas : organo oficial de la Sociedad Espanola de Patologia Digestiva, 2018 May 3     [PubMed]
Minimally Invasive Incision and Drainage Technique in the Treatment of Simple Subcutaneous Abscess in Adults., Salfity HV,Valsangkar N,Schultz M,Salfity J,Stanton-Maxey KJ,Zarzaur B,Feliciano DV,Laughlin MR,, The American surgeon, 2017 Jul 1     [PubMed]
Chronic Granulomatous Disease, Leiding JW,Holland SM,,, 1993     [PubMed]
Perianal Abscess and Proctitis by Klebsiella pneumoniae., Jeong WS,Choi SY,Jeong EH,Bang KB,Park SS,Lee DS,Park DI,Jung YS,, Intestinal research, 2015 Jan     [PubMed]
Endoscopic Ultrasound Guided Perirectal Abscess Drainage Using a Novel Lumen-Apposing Covered Metal Stent., Javed S,Ho S,, The American journal of gastroenterology, 2016 Oct     [PubMed]

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