Perirectal Abscess 

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

Background

Perirectal and perianal abscess are commonly encountered emergency department (ED) problems. Timely and appropriate treatment is needed to prevent serious morbidity and mortality.

This article focuses on perirectal abscess and provides some discussion of perianal abscess. These entities are distinct, with potentially different ED evaluation and different treatment and disposition. Differentiation of the more complex perirectal abscess from the simpler perianal abscess is crucial.

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Pathophysiology

The majority of perirectal abscesses are caused by obstruction of the anal glands, with obstructing debris leading to infection. Most individual have about 6-8 of these glands lying at the level of the dentate line, which divides the squamous epithelium distally and the columnar epithelium proximally. These obstructed anal glands lead to stasis, bacterial overgrowth, and abscess formation that extends into the intersphincteric groove between the internal and external anal sphincter.[1]

Anorectal abscesses are classified according to their location. Perianal abscesses are the most common, extending superficially to the anal verge, where they may be easily incised and drained.[1, 2, 3, 4]

Intersphincteric or submucosal abscesses may collect between the internal and external anal sphincters and lie completely within the anal canal, leading to severe pain, and may only be found by digital rectal examination or anoscopy.

Ischiorectal abscesses may form from the purulent drainage tracking across the external anal sphincter into the deep ischiorectal fossa. These abscesses may traverse the deep postanal space into the contralateral side, forming a “horseshoe abscess.”

Supralevator abscesses are less common and may form from cephalad extension of the intersphincteric abscess above the levator ani muscle or from caudal extension of a suppurative abdominal process into the supralevator space. These abscesses may be diagnosed based on CT scan findings, and they cause pelvic and rectal pain.

Approximately 10% of perirectal abscesses may be caused by reasons other than anal gland infection. These abscesses may be sequelae of Crohn disease, trauma, human immunodeficiency virus (HIV) infection, sexually transmitted diseases, radiation therapy, or foreign bodies.[1]

Both aerobic and anaerobic bacteria are responsible for abscess formation. The predominant anaerobic species are most commonly Bacteroides fragilis, Peptostreptococcus, Prevotella, Fusobacterium, Porphyromonas, and Clostridium. The predominant aerobic bacteria include Staphylococcus aureus, Streptococcus, and Escherichia coli.[5] More recent studies have noted community-acquired methicillin-resistant S aureus (MRSA) as a pathogen leading to abscess formation.[6, 7]

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Epidemiology

Mortality/Morbidity

The overall mortality from perirectal abscesses is quite low.[2]

According to previous data, recurrent abscess formation occurs in approximately 10% of patients, with chronic fistula-in-ano occurring in up to 50% of patients.[2, 8] In more recent literature,[9] 37% of patients develop chronic anal fistula or recurrent sepsis. In this study, risk factors were age younger than 40 years and nondiabetic status; no difference in these complications was noted with regard to HIV status, sex, antibiotic usage, or smoking status.

After anal fistula formation, multiple complications may develop after surgical treatment. Up to 43% of patients have reported fecal incontinence after surgical fistula repair for complex fistula-in-ano.[10] Other postoperative complications from surgical repair include temporary postejaculation urethral irritation and postoperative urinary retention.[11] Constipation may also occur as a result of pain on defecation.

Race

No racial predilection has been found.

Sex

The incidence of perirectal abscess in men is 2- to 3-fold that of women.[12]

Age

Anorectal abscesses most often present in the third to fourth decade.[12]

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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
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  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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