Guidelines
WSES/AAST Guidelines for Management of Anorectal Abscess
In 2021, the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) published guidelines for the management of anorectal emergencies. [32] Recommendations for anorectal abscess included the following:
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In patients with suspected anorectal abscess, a focused medical history and a complete physical examination, including a digital rectal examination (DRE), are suggested.
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In patients with suspected anorectal abscess, it is suggested that serum glucose, hemoglobin a1c, and urine ketones be checked to identify undetected diabetes mellitus.
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In patients with suspected anorectal abscess and signs of systemic infection or sepsis, a complete blood count, serum creatinine, and inflammatory markers (eg, C-reactive protein, procalcitonin, and lactates) are suggested.
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In patients with suspected anorectal abscess, imaging investigations are suggested in case of atypical presentation and in case of suspicion of occult supralevator abscesses, complex anal fistula, or perianal Crohn disease. Magnetic resonance imaging (MRI), computed tomography (CT) scan, or endosonography may be considered, according to the specific clinical scenario and the available skills and resources.
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In patients with anorectal abscess, a surgical approach with incision and drainage is recommended. It is suggested that the timing of surgery be based on the presence and severity of sepsis.
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In fit, immunocompetent patients with a small perianal abscess and no systemic signs of sepsis, outpatient management may be considered.
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No recommendation can be made regarding the use of packing after drainage of an anorectal abscess.
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In patients with an anorectal abscess and an obvious fistula, fistulotomy at the time of abscess drainage is suggested only in the case of a low fistula that does not involve any sphincter muscle (ie, a subcutaneous fistula). If there is an obvious fistula that involves any sphincter muscle, placement of a loose draining seton is suggested.
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In patients with anorectal abscess and no obvious fistula, probing to search for a possible fistula is not suggested, so as to avoid iatrogenic complications.
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In patients with a drained anorectal abscess, antibiotic administration is suggested in the presence of sepsis or surrounding soft-tissue infection or in the case of a disturbed immune response.
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Sampling of drained pus is suggested in high-risk patients or in the presence of risk factors for infection by a multidrug-resistant organism.
Media Gallery
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Illustration of major types of anorectal abscesses (submucosal type not pictured).
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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.
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Goodsall rule for anorectal fistulas. Note curved nature of posterior fistulas and radial (straight) orientation of anterior fistulas.
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