Perirectal Abscess Treatment & Management

Recognition of a perirectal abscess is the primary ED goal. Determination of the exact anatomic space or spaces involved is best left to the surgical consultant.

The isolated perianal abscess that is not associated with deeper, perirectal abscesses is the only type of anorectal abscess that can be adequately treated in an ED setting and is very rare.

Perirectal abscess must be treated in the operating suite, where optimal anesthesia can be achieved and the abscess and any fistula or other complication may be treated definitively. The "point" of a deep abscess must not be mistaken for a superficial perianal abscess. Inadequate ED debridement of a perirectal abscess may result in increased morbidity and even mortality. ED debridement of perirectal abscesses should not be performed. Because the ED lacks adequate anesthesia, ED treatment of perirectal abscesses is inhumane.

A simple (and, by definition, superficial) perianal abscess may be incised and drained in the ED. Adequate analgesia should be obtained by using the steps discussed in Procedures. Conscious sedation may be considered for pain control and to make the procedure as humane as possible. The patient may be discharged home after appropriate wound care with instructions for Sitz baths and routine follow-up care.

Superficial perianal abscesses are uncommon; thus, the provider should err on the side of assuming a deeper process exists if the diagnosis is in doubt.

• As an example, optimal treatment of ischiorectal abscesses is incision and drainage often followed by fistulotomy under general anesthesia in the operating suite.

  • The performance of an extensive and complete surgical procedure by a consultant with accurate anatomical knowledge of the region is imperative to avoid serious complications. Such treatment results in a lower recurrence rate.
  • The need for the routine use of antibiotics has not been established. Intravenous antibiotics may be used as preventive or therapeutic measures in patients who are immunocompromised, in those who appear septic, or in those who have heart valve abnormalities or prostheses.
  • Ascertain tetanus immunity. When acceptable immunity cannot be established, follow the currently recommended guidelines for high-risk wounds.
• The goal in treating any abscess is to make an incision to surgically release pus and to remove any dead tissue, and then to keep the surgical incision open by the use of a drain, either (1) a Penrose drain, which may be sutured to the incisional margin and later removed, or (2) iodoform gauze stripping. In the case of perianal abscess, the procedure involves sterile preparation, adequate analgesia, incision and drainage often facilitated by irrigation of the abscess cavity, blunt disruption of any loculations (a gloved fingertip is ideal for this), debridement of any accessible necrotic tissue, and placement of a drain.

  • Do not pack the abscess full of iodoform gauze. The intent is to keep the surgical incision open so that pus and other material can drain. If iodoform gauze stripping is used, using a limited amount of gauze is important, that is, just enough to keep the wound open. Packing the wound full of iodoform gauze does not improve the outcome, and, in fact, it may worsen the prognosis by creating a large foreign body that may become a nidus of infection. This nidus could perpetuate the infection and cause the abscess to enlarge, spread to other areas, erode into vessels or into the peritoneal cavity, and, occasionally, it could cause sepsis and death.
  • In one pediatric case, an incision and drainage (I&D) and packing was performed on a large perirectal abscess in the ED. This packing was left in the wound for days. Shortly thereafter, sepsis and seeding of the myocardium developed with a resultant myocardial abscess. This myocardial abscess eventually ruptured into the pericardial sac, causing tamponade and sudden death.

• When the diagnosis of perirectal abscess is made or is being entertained, expeditious consultation with a surgeon is mandatory.

  • Timely and appropriate operative treatment prevents more serious complications such as extension of the abscess or serious systemic infection.
  • The appropriate surgical treatment of perirectal abscess is complex and painful and therefore should not be undertaken in the ED. General or spinal anesthesia is necessary to obtain the appropriate anesthetic result.
  • A newer technique includes endoscopic ultrasonographic-guided drainage of deep pelvic abscesses with stent placement for drainage of pus. In one study, this technique successfully treated most patients who underwent this treatment, requiring no further intervention.