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Updated: Dec 15 2021

Perirectal / Perianal Abscess

  • Snapshot
    • A 41-year-old man presents to the emergency department with 2 days of worsening fever and severe pain in his rectum, worse with defecation. His medical history is significant for type 2 diabetes mellitus and morbid obesity. On physical exam, he has a fever of 39°C and a warm, fluctuant 2-cm mass is palpated immediately adjacent to the anus with surrounding cellulitis. Incision and drainage is performed at the bedside, and the patient is discharged with a course of oral ciprofloxacin and metronidazole.
  • Introduction
    • Clinical definition
      • an abscess of the rectum, anus, or adjacent tissues
    • Genetics
      • not inherited
      • increased susceptibility in inherited immunodeficiencies
    • Associated conditions
      • Crohn disease
      • fistula-in-ano/perianal fistula
  • Epidemiology
    • Demographics
      • 2:1 male to female
      • middle age
        • roughly 20-60 years of age with a mean age of 40 for both sexes
      • occurs rarely in children
    • Risk factors
      • Crohn disease
      • immunodeficiency
        • diabetes
        • chronic corticosteroid use
    • Pathogenesis
      • obstruction and infection of an anal gland
      • may spread to contiguous areas (e.g. perianal, ischiorectal, and intersphincteric) through the extensive branching of the anal gland network
  • Presentation
    • Symptoms
      • perirectal/perianal pain
      • fever
      • local swelling
      • less commonly diarrhea and/or constipation
    • Physical exam
      • perirectal/perianal tenderness
      • palpable mass
      • fever
      • surrounding cellulitis
  • imaging
    • Generally not required for the diagnosis of anorectal abscesses
      • may be necessary to diagnose occult abscesses or to define the extent of large or complicated abscesses
      • used in patients with concurrent Crohn disease
    • No clear first-line among the following modalities
      • endoanal ultrasound
      • MRI with contrast
      • CT with contrast
  • Studies
    • Diagnostic testing
      • diagnostic approach
        • diagnosis is based on history and clinical exam
        • if clinical exam cannot be performed in the office (e.g., due to pain)
          • examination under anesthesia (EUA) may be necessary
  • Differential
    • Anal fissure
      • differentiating factors
        • visualizable tear, bleeding, no mass, and no signs of infection
    • Hemorrhoids
      • differentiating factors
        • bleeding and no signs of infection
    • Pilonidal abscess
      • differentiating factors
        • location alone
  • Treatment
    • First-line
      • incision and drainage
        • early, adequate, and dependent drainage yields best results
          • more superficial abscesses may be drained in the office
          • deeper may require the operating room
    • Other treatments
      • antibiotics
        • never indicated alone
          • only in addition to drainage
        • indications
          • accompanying cellulitis
          • systemic signs of infection
          • immunosuppressed patients
            • including
              • HIV/AIDS
              • diabetes
              • morbid obesity
        • typically metronidazole and a fluoroquinolone (e.g., ciprofloxacin)
          • covers MRSA and gut flora
  • Complications
    • Anorectal fistula/fistula-in-ano
      • 30-70% will present with concurrent fistula
      • an additional 33% will eventually develop a fistula after drainage
    • Recurrent abscess
    • Sepsis
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