Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Anorectal Abscess Medication

  • Author: Andre Hebra, MD; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Dec 16, 2015
 

Medication Summary

Antibiotics are unnecessary in otherwise healthy individuals. The practitioner should provide appropriate empiric intravenous (IV) antibiotic coverage for patients who are elderly or immunosuppressed, patients who have comorbidities, patients with a heart valve abnormality or prosthetic valve who are likely to benefit from antibiotic prophylaxis, and patients in whom infection has become systemic.

Analgesia is necessary for pain control and may be given orally (PO) or IV, in conjunction with anesthetics if needle aspiration or incision and drainage of an abscess are performed. Anxiolytics may help certain patients who are apprehensive about needle aspiration, incision and drainage, imaging studies, or surgery.

Next

Antibiotics

Class Summary

Appropriate IV antibiotic coverage should be provided preoperatively and postoperatively, either on the basis of Gram staining or on an empiric basis, as a preventive measure, for elderly patients, patients with immunosuppression, patients with a heart valve abnormality or prosthesis, and patients with comorbid states.

Ampicillin-sulbactam (Unasyn)

 

Ampicillin-sulbactam represents a combination of a beta-lactamase inhibitor with a penicillin. It interferes with bacterial cell-wall synthesis during active replication, causing bactericidal activity against susceptible organisms. It is used as an alternative to amoxicillin when a patient is unable to take medication PO. Ampicillin-sulbactam covers skin, enteric flora, and anaerobes; it is not ideal for nosocomial pathogens.

Imipenem-cilastatin (Primaxin)

 

Imipenem-cilastatin should be used empirically for more severely ill intensive care unit (ICU) patients. Pus or blood culture and sensitivity results, once available, should guide antibiotic selection. Predisposing and comorbid diseases may also guide empiric antibiotic selection.

Ampicillin

 

Ampicillin, a broad-spectrum penicillin, interferes with bacterial cell-wall synthesis during active replication, causing bactericidal activity against susceptible organisms. It is used as an alternative to amoxicillin when a patient is unable to take medication PO. Patients with prosthetic heart valves who are at risk for endocarditis should receive IV prophylactic antibiotics before any procedure. Ampicillin is preferred for this application, unless the patient is penicillin-allergic, in which case cefazolin or clindamycin is an appropriate choice.

Cefazolin

 

Cefazolin is a first-generation semisynthetic cephalosporin that binds to one or more penicillin-binding proteins, arresting bacterial cell wall synthesis and inhibiting bacterial replication. It has poor capacity to cross the blood-brain barrier. Cefazolin is primarily active against skin flora, including Staphylococcus aureus, and is typically used alone for skin and skin-structure coverage. Regimens for IV and intramuscular (IM) dosing are similar. This agent is used in penicillin-allergic patients with prosthetic heart valves who are at risk for endocarditis.

Clindamycin (Cleocin)

 

Clindamycin is a semisynthetic antibiotic produced by 7(S)-chloro-substitution of the 7(R)-hydroxyl group of the parent compound, lincomycin. It inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Clindamycin is widely distributed in the body without penetrating the central nervous system (CNS). It is protein-bound and excreted by the liver and kidneys. This agent is used in penicillin-allergic patients with prosthetic heart valves at risk for endocarditis.

Previous
Next

Anesthetics

Class Summary

Anesthetics may help blunt the pain of a diagnostic needle aspiration but are only partially effective.

Lidocaine 1% (Xylocaine with Epinephrine)

 

Lidocaine 1-2% with or without epinephrine (1:100,000 or 1:200,000 concentration) is used. Lidocaine is an amide local anesthetic used in 1-2% concentration. The 1% preparation contains 10 mg of lidocaine for each 1 mL of solution; the 2% preparation contains 20 mg of lidocaine for each 1 mL of solution. Lidocaine inhibits depolarization of type C sensory neurons by blocking sodium channels. Epinephrine prolongs the duration of the anesthetic effects from lidocaine by causing vasoconstriction of the blood vessels surrounding the nerve axons.

Lidocaine decreases permeability to sodium ions in neuronal membranes. This results in inhibition of depolarization, blocking the transmission of nerve impulses. Epinephrine prolongs the duration of the anesthetic effects from lidocaine by causing vasoconstriction of the blood vessels surrounding the nerve axons.

Ethylene chloride may be used in conjunction with lidocaine to blunt the pain of a diagnostic needle aspiration but is only partially effective. It should be sprayed over the area to be aspirated immediately before aspiration.

Bupivacaine and epinephrine (Marcaine with Epinephrine, Vivacaine, Sensorcaine with Epinephrine)

 

Bupivacaine decreases permeability to sodium ions in neuronal membranes. This results in the inhibition of depolarization, blocking the transmission of nerve impulses. Epinephrine prolongs the duration of the anesthetic effects from bupivacaine by causing vasoconstriction of the blood vessels surrounding the nerve axons.

Previous
Next

Pain Medications

Class Summary

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and possess sedating properties, which are beneficial for patients who experience pain. These agents are used for comfort and sedation and to blunt the discomfort of diagnostic needle aspiration.

Meperidine (Demerol, Meperitab)

 

Meperidine is an analgesic with multiple actions similar to those of morphine; it may produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine. Meperidine may be used in combination with promethazine to provide a synergistic effect.

Previous
Next

Antiemetics

Class Summary

Antiemetic agents are used to treat vomiting. In combination with analgesics like meperidine, it may produce a synergistic effect.

Promethazine (Phenergan)

 

Promethazine is an antidopaminergic agent that is effective in treating emesis. It blocks postsynaptic mesolimbic dopaminergic receptors in the brain and reduces stimuli to the brainstem reticular system. It may be used in combination with meperidine to provide a synergistic effect.

Previous
Next

Benzodiazepines

Class Summary

By binding to specific receptor sites, benzodiazepines appear to potentiate the effects of gamma-aminobutyric acid (GABA) and to facilitate neurotransmission of GABA and other inhibitory transmitters. These agents are anxiolytics that may help patients who are apprehensive about needle aspiration, imaging studies, or surgery. Conscious sedation may be considered by the emergency physician with equipment and experience necessary to manage the patient’s airway if spontaneous ventilation becomes compromised.

Midazolam

 

Midazolam is a shorter-acting benzodiazepine sedative-hypnotic that is useful in patients who require acute or short-term sedation. It is also useful for its amnestic effects.

Lorazepam (Ativan)

 

Lorazepam is a sedative-hypnotic that increases the action of GABA, thereby potentially depressing all levels of the CNS, including the limbic system and reticular formation. It has a short onset of effect and a relatively long half-life. When patient needs to be sedated for longer than 24 hours, this medication is excellent.

Previous
 
Contributor Information and Disclosures
Author

Andre Hebra, MD Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine; Surgeon-in-Chief, Medical University of South Carolina Children's Hospital

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, Florida Medical Association, Society of American Gastrointestinal and Endoscopic Surgeons, Children's Oncology Group, International Pediatric Endosurgery Group, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Acknowledgements

Marc D Basson, MD, PhD, MBA, FACS Professor, Chair, Department of Surgery, Assistant Dean for Faculty Development in Research, Michigan State University College of Human Medicine

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, and Sigma Xi

Disclosure: Nothing to disclose.

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Eugene Hardin, MD, FAAEM, FACEP Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

Nizar Kifaieh, MD, FACEP Assistant Professor, Medical Director, Department Of Emergency Medicine, State University of New York Downstate Medical Center

Nizar Kifaieh, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Medical Association, New York County Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Patrick B Thomas, MD Fellow, Department of Pediatric Surgery, Texas Children's Hospital

Disclosure: Nothing to disclose.

Walter W Valesky Jr, MD Clinical Assistant Instructor, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate Medical Center

Disclosure: Nothing to disclose.

References
  1. Whiteford MH. Perianal abscess/fistula disease. Clin Colon Rectal Surg. 2007 May. 20(2):102-9. [Medline]. [Full Text].

  2. Marcus RH, Stine RJ, Cohen MA. Perirectal abscess. Ann Emerg Med. 1995 May. 25(5):597-603. [Medline].

  3. Pfenninger JL, Zainea GG. Common anorectal conditions: Part II. Lesions. Am Fam Physician. 2001 Jul 1. 64(1):77-88. [Medline].

  4. Rizzo JA, Naig AL, Johnson EK. Anorectal abscess and fistula-in-ano: evidence-based management. Surg Clin North Am. 2010 Feb. 90(1):45-68, Table of Contents. [Medline].

  5. Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg. 1976 Jan. 63(1):1-12. [Medline].

  6. Hamadani A, Haigh PI, Liu IL, Abbas MA. Who is at risk for developing chronic anal fistula or recurrent anal sepsis after initial perianal abscess?. Dis Colon Rectum. 2009 Feb. 52(2):217-21. [Medline].

  7. Brook I, Frazier EH. The aerobic and anaerobic bacteriology of perirectal abscesses. J Clin Microbiol. 1997 Nov. 35(11):2974-6. [Medline]. [Full Text].

  8. Albright JB, Pidala MJ, Cali JR, Snyder MJ, Voloyiannis T, Bailey HR. MRSA-related perianal abscesses: an underrecognized disease entity. Dis Colon Rectum. 2007 Jul. 50(7):996-1003. [Medline].

  9. Brown SR, Horton JD, Davis KG. Perirectal abscess infections related to MRSA: a prevalent and underrecognized pathogen. J Surg Educ. 2009 Sep-Oct. 66(5):264-6. [Medline].

  10. Beard JM, Osborn J. Anorectal Abscess. Rakel RE, Rakel DP, eds. Textbook of Family Medicine. 8th ed. Philadelphia, Pa: Saunders; 2011.

  11. Novotny NM, Mann MJ, Rescorla FJ. Fistula in ano in infants: who recurs?. Pediatr Surg Int. 2008 Nov. 24(11):1197-9. [Medline].

  12. Hämäläinen KP, Sainio AP. Incidence of fistulas after drainage of acute anorectal abscesses. Dis Colon Rectum. 1998 Nov. 41(11):1357-61; discussion 1361-2. [Medline].

  13. Athanasiadis S, Köhler A, Nafe M. Treatment of high anal fistulae by primary occlusion of the internal ostium, drainage of the intersphincteric space, and mucosal advancement flap. Int J Colorectal Dis. 1994 Aug. 9(3):153-7. [Medline].

  14. Abbas MA, Lemus-Rangel R, Hamadani A. Long-term outcome of endorectal advancement flap for complex anorectal fistulae. Am Surg. 2008 Oct. 74(10):921-4. [Medline].

  15. Hyman N, O'Brien S, Osler T. Outcomes after fistulotomy: results of a prospective, multicenter regional study. Dis Colon Rectum. 2009. 52:2022-7. [Medline].

  16. Weizberg M, Gillett BP, Sinert RH. Penile discharge as a presentation of perirectal abscess. J Emerg Med. 2008 Jan. 34(1):45-7. [Medline].

  17. Smereck J, Ybarra M. Acute hip pain and inability to ambulate: a rare presentation for perirectal abscess. Am J Emerg Med. 2011 Mar. 29(3):356.e1-3. [Medline].

  18. Bennetsen DT. Perirectal abscess after accidental toothpick ingestion. J Emerg Med. 2008 Feb. 34(2):203-4. [Medline].

  19. Erhan Y, Sakarya A, Aydede H, Demir A, Seyhan A, Atici E. A case of large mucinous adenocarcinoma arising in a long-standing fistula-in-ano. Dig Surg. 2003. 20(1):69-71. [Medline].

  20. Fish D, Kugathasan S. Inflammatory bowel disease. Adolesc Med Clin. 2004 Feb. 15(1):67-90, ix. [Medline].

  21. [Guideline] Whiteford MH, Kilkenny J 3rd, Hyman N, Buie WD, Cohen J, Orsay C, et al. Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised). Dis Colon Rectum. 2005 Jul. 48(7):1337-42. [Medline].

  22. Sözener U, Gedik E, Kessaf Aslar A, Ergun H, Halil Elhan A, Memikoglu O, et al. Does adjuvant antibiotic treatment after drainage of anorectal abscess prevent development of anal fistulas? A randomized, placebo-controlled, double-blind, multicenter study. Dis Colon Rectum. 2011 Aug. 54(8):923-9. [Medline].

  23. Chandwani D, Shih R, Cochrane D. Bedside emergency ultrasonography in the evaluation of a perirectal abscess. Am J Emerg Med. 2004 Jul. 22(4):315. [Medline].

  24. Tio TL, Mulder CJ, Wijers OB, et al. Endosonography of peri-anal and peri-colorectal fistula and/or abscess in Crohn's disease. Gastrointest Endosc. 1990 Jul-Aug. 36(4):331-6. [Medline].

  25. Caliste X, Nazir S, Goode T, Street JH 3rd, Hockstein M, McArthur K, et al. Sensitivity of computed tomography in detection of perirectal abscess. Am Surg. 2011 Feb. 77(2):166-8. [Medline].

  26. Berton F, Gola G, Wilson SR. Sonography of benign conditions of the anal canal: an update. AJR Am J Roentgenol. 2007 Oct. 189(4):765-73. [Medline].

  27. Stewart LK, McGee J, Wilson SR. Transperineal and transvaginal sonography of perianal inflammatory disease. AJR Am J Roentgenol. 2001 Sep. 177(3):627-32. [Medline].

  28. Buchanan GN, Halligan S, Bartram CI, Williams AB, Tarroni D, Cohen CR. Clinical examination, endosonography, and MR imaging in preoperative assessment of fistula in ano: comparison with outcome-based reference standard. Radiology. 2004 Dec. 233(3):674-81. [Medline].

  29. Domkundwar SV, Shinagare AB. Role of transcutaneous perianal ultrasonography in evaluation of fistulas in ano. J Ultrasound Med. 2007 Jan. 26(1):29-36. [Medline].

  30. Berman L, Israel GM, McCarthy SM, Weinreb JC, Longo WE. Utility of magnetic resonance imaging in anorectal disease. World J Gastroenterol. 2007 Jun 21. 13(23):3153-8. [Medline].

  31. Waniczek D, Adamczyk T, Arendt J, Kluczewska E, Kozinska-Marek E. Usefulness assessment of preoperative MRI fistulography in patients with perianal fistulas. Pol J Radiol. 2011 Oct. 76(4):40-4. [Medline]. [Full Text].

  32. Corman ML. Colon and Rectal Surgery. 4th ed. Philadelphia, Pa: Lippincott-Raven; 1998. 224-71.

  33. Dozois RR, Nichols JR. Surgery of the Colon and Rectum. New York, NY: Churchill Livingstone; 1997. 255-84.

  34. Lunniss PJ, Phillips RKS. Anal Fistula: Surgical Evaluation and Management. London, England: Chapman & Hall; 1996. 1-183.

  35. Nelson R. Anorectal abscess fistula: what do we know?. Surg Clin North Am. 2002 Dec. 82(6):1139-51, v-vi. [Medline].

  36. Gordon PH, Nivatvongs S, eds. Principles and Practice of Surgery for the Colon, Rectum and Anus. St Louis, Mo: Quality Medical Pub; 1999. 241-86.

  37. Peng KT, Hsieh MC, Hsu WH, Li YY, Yeh CH. Anterior ilioinguinal incision for drainage of high-located perianal abscess. Tech Coloproctol. 2012 Sep 28. [Medline].

  38. Buddicom E, Jamieson A, Beasley S, King S. Perianal abscess in children: aiming for optimal management. ANZ J Surg. 2012 Jan-Feb. 82(1-2):60-2. [Medline].

  39. Galandiuk S, Kimberling J, Al-Mishlab TG, et al. Perianal Crohn disease: predictors of need for permanent diversion. Ann Surg. 2005 May. 241(5):796-801; discussion 801-2. [Medline]. [Full Text].

  40. Guidi L, Ratto C, Semeraro S, et al. Combined therapy with infliximab and seton drainage for perianal fistulizing Crohn's disease with anal endosonographic monitoring: a single-centre experience. Tech Coloproctol. 2008 Jun. 12(2):111-7. [Medline].

  41. Malik AI, Nelson RL. Surgical management of anal fistulae: a systematic review. Colorectal Dis. 2008 Jun. 10(5):420-30. [Medline].

  42. Yeung JM, Alistair J, Simpson D, et al. Fibrin glue for the treatment of fistulae in ano - a method worth sticking to?. Colorectal Dis. 2009 Feb 7. [Medline].

  43. Gupta PJ. Anal fistulotomy using radiowaves- long-term outcome. Acta Chir Iugosl. 2008. 55(3):115-8. [Medline].

 
Previous
Next
 
Illustration of major types of anorectal abscesses (submucosal type not pictured).
Goodsall rule for anorectal fistulas. Fistulas that exit in posterior half of rectum generally follow curved course toward posterior midline, whereas those that exit in anterior half of rectum usually follow radial course to dentate line.
Goodsall rule for anorectal fistulas. Note curved nature of posterior fistulas and radial (straight) orientation of anterior fistulas.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.