eMedicine Specialties > Emergency Medicine > Gastrointestinal

Perirectal Abscess

Author: Drew Evan Fenton, MD, General Practice Physician, Arizona Family Care Associates
Contributor Information and Disclosures

Updated: Aug 15, 2008

Introduction

Background

Perirectal and perianal abscess are commonly encountered 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 more simple perianal abscess is crucial.

Pathophysiology

Perirectal abscess arises from infection of the mucus-secreting anal glands, which drain into the anal crypts. Blockage of the duct is believed to be the initiating cause of infection. The abscess can then progress to involve the potential spaces filled with fatty areolar tissue, which have little resistance to infection. These spaces include the perianal, intersphincteric, ischiorectal, deep postanal space (connecting the ischiorectal space on each side posteriorly), and supralevator spaces. These spaces may become infected alone or in combination with one another.

Perirectal abscess is usually an aerobic and anaerobic polymicrobial infection. Bacteroides fragilis is the predominant anaerobe. Other common bacteria include Escherichia coli and those of the genera Proteus, Bacteroides, and Streptococcus. Sources of bacteria are skin, bowel, and, rarely, the vagina.1

A variety of disease states is associated with the development of an abscess; these include Crohn disease, carcinoma, radiation fibrosis, trauma, Hodgkin disease, and immunocompromised states. Associated infectious causes include Chlamydia, Actinomyces, Gonococcus, Streptococcus, Bacteroides, and Proteus species; Staphylococcus aureus and Escherichia coli; and herpes, tuberculosis, and lymphogranuloma venereum.

In contradistinction to perirectal abscess, perianal abscess is easily palpable and is not accompanied by fever, leukocytosis, and sepsis in the immunocompetent patient.

Mortality/Morbidity

In rare instances, inappropriately treated perirectal abscess may result in death.

  • Perirectal abscess results in fistula formation in 25-50% of cases.
  • Bacteremia and sepsis may result, especially in immunocompromised patients.
  • In infants, fistula formation ensues after drainage of an abscess in 35% of cases.
  • Urinary retention (often resulting in lengthened hospitalization) occurs in 5% of cases.
  • Fournier gangrene has occasionally been reported.

Race

No racial predilection has been found.

Sex

Men are affected more frequently than women, with a male-to-female predominance of 2:1 to 3:1.

Age

Perirectal abscess occurs in all age groups, from infants to elderly persons. The peak incidence is in the third and fourth decades of life.

Clinical

History

The history is critical in leading the physician to consider the diagnosis.

  • Dull, aching, or throbbing pain in the perirectal or perianal area is present in 99% of patients. The pain worsens when sitting and immediately before defecation, when the rectum is full; the pain decreases after defecation but persists between bowel movements. Perianal abscess presents with more localized pain.
    • The pain often worsens as the abscess increases in size.
    • Coughing and sneezing, straining, or any Valsalva maneuver aggravates the pain.
  • Rectal or perirectal drainage (27%)
  • Fever and/or chills (23%)
  • Constipation (13%)
  • Anorexia (12%)

Physical

The physical examination findings may be normal, but a history that raises suspicion of a perirectal abscess should lead the physician to continue to pursue the diagnosis.

  • A tender fluctuant mass may be palpated at the anal verge (perianal abscess) or on rectal examination (perirectal abscess). Perirectal abscess can be extensive and can spread to an area distant from the anal verge, yet only a diffuse, tender mass may be palpable through either the rectal wall or the overlying skin.
  • Fever
  • Localized erythema
  • Purulent drainage
  • Signs of sepsis may be seen in cases of perirectal abscess in which the infection has become systemic.

Causes

The cause of perirectal abscess is believed to be blockage of the perianal gland duct with resultant infection, rupture, and abscess formation. Risk factors are as follows:

More on Perirectal Abscess

Overview: Perirectal Abscess
Differential Diagnoses & Workup: Perirectal Abscess
Treatment & Medication: Perirectal Abscess
Follow-up: Perirectal Abscess
References

References

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

  2. Andersson P, Olaison G, Hallbook O, Boeryd B, Sjodahl R. Increased anal resting pressure and rectal sensitivity in Crohn's disease. Dis Colon Rectum. Dec 2003;46(12):1685-9. [Medline].

  3. Cataldo PA, Senagore A, Luchtefeld MA. Intrarectal ultrasound in the evaluation of perirectal abscesses. Dis Colon Rectum. Jun 1993;36(6):554-8. [Medline].

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

  5. Cuenod CA, de Parades V, Siauve N, Marteau P, Grataloup C, Hernigou A, et al. [MR imaging of ano-perineal suppurations]. J Radiol. Apr 2003;84(4 Pt 2):516-28. [Medline].

  6. Festen C, van Harten H. Perianal abscess and fistula-in-ano in infants. J Pediatr Surg. May 1998;33(5):711-3. [Medline].

  7. Giovannini M, Bories E, Moutardier V, Pesenti C, Guillemin A, Lelong B, et al. Drainage of deep pelvic abscesses using therapeutic echo endoscopy. Endoscopy. Jun 2003;35(6):511-4. [Medline].

  8. Heidemann J, Spinelli KS, Otterson MF, Binion DG. Case report: magnetic resonance imaging in the diagnosis of epidural abscess complicating perirectal fistulizing Crohn's disease. Inflamm Bowel Dis. Mar 2003;9(2):122-4. [Medline].

  9. Kattan S, Youssef A. Fournier's gangrene of the scrotum following anorectal disorders. Int Urol Nephrol. 1994;26(2):215-22. [Medline].

  10. Laniado M, Makowiec F, Dammann F, Jehle EC, Claussen CD, Starlinger M. Perianal complications of Crohn disease: MR imaging findings. Eur Radiol. 1997;7(7):1035-42. [Medline].

  11. Lobo Martínez E, Torres Aleman A, Galindo Alvarez J, Martinez Molina E. Endoanal ultrasound in perirectal abscesses. Rev Esp Enferm Dig. Dec 1997;89(12):897-902. [Medline].

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

  13. Nomikos IN. Anorectal abscesses: need for accurate anatomical localization of the disease. Clin Anat. 1997;10(4):239-44. [Medline].

  14. Rubens DJ, Strang JG, Bogineni-Misra S, Wexler IE. Transperineal sonography of the rectum: anatomy and pathology revealed by sonography compared with CT and MR imaging. AJR Am J Roentgenol. Mar 1998;170(3):637-42. [Medline].

  15. 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].

  16. Stoker J, Rociu E, Wiersma TG, Lameris JS. Imaging of anorectal disease. Br J Surg. Jan 2000;87(1):10-27. [Medline].

  17. Zaheer S, Reilly WT, Pemberton JH, Ilstrup D. Urinary retention after operations for benign anorectal diseases. Dis Colon Rectum. Jun 1998;41(6):696-704. [Medline].

Further Reading

Keywords

perirectal abscess, perianal abscess, infection of the mucus-secreting anal glands, anorectal abscess

Contributor Information and Disclosures

Author

Drew Evan Fenton, MD, General Practice Physician, Arizona Family Care Associates
Drew Evan Fenton, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Michael S Beeson, MD, MBA, FACEP, Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine; Program Director, Emergency Medicine Residency, Summa Health System
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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eugene Hardin, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles R Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King, Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

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

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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