Perirectal Abscess Clinical Presentation

  • Author: Walter W Valesky Jr, MD; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: Feb 14, 2012
 

History

Almost all perirectal abscesses are associated with perirectal pain that is indolent in nature. In one study, approximately half the patients with perirectal abscesses also presented with swelling around the rectum, with approximately a quarter of patients presenting with rectal or perirectal drainage that may be bloody, purulent, or mucoid. These patients may also present with constipation, most likely due to pain on defecation, but the absence of constipation or even diarrhea does not rule out the diagnosis. The majority of these patients deny a history of fever or chills. In many cases, these patients may delay presentation to a physician or they might have already presented to a physician and have been given alternative diagnoses. Furthermore, complaints of abdominal pain are rare in these patients.[2, 4]

In addition to these symptoms, various case reports in the literature describe perirectal abscesses presenting with penile discharge, hip pain, or post foreign body ingestion.[13, 14, 15]

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Physical

Patients with perirectal abscesses usually have normal vital signs on initial evaluation, with only 21% of patients reporting fevers or chills. Rectal examination usually reveals an area of localized tenderness, fluctuance, erythema, or drainage. However, one study reported clinicians unable to identify abscesses in 10% of patients on rectal examination, with 4% in this series showing no signs of perirectal abscesses on initial examination.[2] If clinical suspicion is high and the physical examination is unremarkable, the patient may require examination under anesthesia.[4]

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Causes

The cause of 90% of perirectal abscesses is believed to be due to blockage of anal glands and bacterial overgrowth.[4] This may be due to increased sphincter tone leading to duct obstruction.[9] Other predisposing causes are immunodeficiency such as that resulting from HIV infection and malignancy (both hematologic and anorectal cancer), hidradenitis suppurativa, foreign bodies, radiation therapy, perforated diverticular disease, inflammatory bowel disease, or appendicitis, which rarely can lead to supralevator abscesses.

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

Nizar Kifaieh, MD, FACEP  Assistant Professor, Associate 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.

Specialty Editor Board

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.

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

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.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

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.

References

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

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

  3. Pfenninger JL, Zainea GG. Common anorectal conditions: Part II. Lesions. Am Fam Physician. Jul 1 2001;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. Feb 2010;90(1):45-68, Table of Contents. [Medline].

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

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

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

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

  9. 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. Feb 2009;52(2):217-21. [Medline].

  10. 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. Aug 1994;9(3):153-7. [Medline].

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

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

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

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

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

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

  17. Sözener U, Gedik E, Kessaf Aslar A, 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. Aug 2011;54(8):923-9. [Medline].

  18. Caliste X, Nazir S, Goode T, et al. Sensitivity of computed tomography in detection of perirectal abscess. Am Surg. Feb 2011;77(2):166-8. [Medline].

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

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

  21. 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. Dec 2004;233(3):674-81. [Medline].

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

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

  24. 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].

 
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