Perianal Cysts Treatment & Management

Updated: Aug 17, 2021
  • Author: Ruben Peralta, MD, FACS; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Treatment

Approach Considerations

No particular medical treatment is available for perianal cysts. Complete surgical excision is the treatment of choice. As for any procedure, surgical treatment is contraindicated if the patient is a poor operative candidate. Careful risk-benefit consideration is needed for individuals with severe pulmonary and/or cardiac disease.

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Surgical Excision

The majority of sacrococcygeal teratomas can be removed through a sacral approach; however, if the tumor extends greatly into the pelvis and retroperitoneum, an additional abdominal incision may be necessary for complete excision of the tumor. Laparoscopic approaches have been described. [17, 18]  For sacrococcygeal teratomas, it is recommended that the coccyx also be removed; failure to remove it has been associated with a high risk of recurrence. 

For histologically benign teratomas, adequate surgical excision is virtually curative. [19] For malignant teratomas, surgical excision alone is inadequate, and patients should receive additional treatment with chemotherapy, radiotherapy, or both. It has been suggested that same low-stage sacrococcygeal teratomas may be treatable with resection and observation alone, with chemotherapy provided only in the event of recurrence. [20]

Of special concern is the association between genetic presacral teratomas and urinary and anal anomalies. The Currarino triad is an autosomal dominant condition that includes anorectal stenosis, a sacral bony anomaly in which the sacrum has a crescent shape, and a presacral mass. [21] This mass can be a teratoma and is rarely malignant. [22] In these cases, care should be taken when excising the mass, because there may be communication with the dura mater and the cerebrospinal fluid (CSF).

For the three other cyst types, a transrectal approach may be used. If an abscess is suggested, incision and drainage are recommended, with an appropriate course of antibiotics.

The fetus with sacrococcygeal teratoma has an increased risk of perinatal complications (eg, from tumor rupture or dystocia). In some cases, in-utero interventions such as tumor debulking and cyst aspiration may be considered.

Sananes et al conducted a retrospective study of fetuses with high-risk large sacrococcygeal teratomas with the aims of assessing the efficacy of minimally invasive ablation of these tumors and determining the relative efficacy of vascular and interstitial ablation. [23]  They found that this minimally invasive approach appeared to improve outcome and that vascular ablation might be superior to interstitial ablation, but they noted that the latter finding would require further investigation in a larger multicenter prospective study.

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Postoperative Care

No particular diet affects the natural history of these cysts. However, patients should be placed on a high-fiber diet postoperatively to prevent straining-induced wound dehiscence.

Patients with perianal cysts are not limited in their activities. Postoperatively, patients may find sitz baths helpful for decreasing their discomfort.

Postoperative chemotherapy or radiotherapy may be necessary in patients with malignant teratomas or teratomas with malignant transformation. Because sacrococcygeal teratomas are rare, no standard recommendation exists for the use of chemotherapy or radiation therapy.

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Complications

Bleeding and infection are potential complications of any surgical procedure. Profuse bleeding is rarely a major complication, because no major blood vessels are present in the perianal region. Good hygiene during wound healing can reduce the risk of infection.

Fistula formation is a rare complication; however, the risk may be slightly increased in dermoid cysts because they may contain hair projecting from a sinus tract.

Fecal incontinence also is a rare complication; the risk depends on the position of the cyst and on the age, sex, and past medical history of the patient.

In children, sacrococcygeal teratomas can cause such problems as ureteric obstruction and resultant hydronephrosis (urinary tract dilation). Neurogenic bladder is a potential complication of sacrococcygeal teratoma and of its surgical treatment. [24]

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Consultations

A colorectal surgeon may be consulted to aid in the excision of the cyst. The patient also may be referred to a dermatologist if anal skin cancer or perianal dermatoses are suggested.

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Long-Term Monitoring

Only in rare cases is inpatient care necessary for the management of perianal cysts. For sacrococcygeal teratomas, however, postoperative outpatient follow-up is crucial. [25] If complete resection is accomplished, a full physical examination should be performed periodically, with emphasis on assessment of the perineal and presacral area by rectal examination. Computed tomography (CT) or magnetic resonance imaging (MRI) may be useful if a recurrence is suggested.

For the other three types of cysts, follow-up with a physician for assessment of wound healing and fecal incontinence is recommended. Chemotherapy and/or radiotherapy may be necessary for patients diagnosed with malignancy.

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