From the Guidelines
The primary treatment for a perianal abscess is immediate surgical drainage, which should be performed as soon as possible to reduce the risk of complications and improve patient outcomes. This approach is supported by the most recent and highest quality study available, which recommends a surgical approach with incision and drainage for patients with anorectal abscess 1.
Diagnosis and Initial Management
The diagnosis of a perianal abscess is typically made through physical examination and, if necessary, imaging such as CT or MRI. The use of imaging investigations is suggested in cases of atypical presentation, suspicion of occult supralevator abscesses, complex anal fistula, or perianal Crohn’s disease 1.
Surgical Drainage
Surgical drainage is the primary treatment for perianal abscesses. The procedure involves incision and drainage under local anesthesia for small abscesses or general anesthesia for larger or complex ones. The timing of surgery should be based on the presence and severity of sepsis, with emergent drainage recommended for patients with sepsis, severe sepsis, or septic shock 1.
Wound Care and Pain Management
After surgical drainage, the wound should be left open to heal by secondary intention. Patients should be instructed on daily sitz baths and regular dressing changes to promote healing and prevent infection. Pain management is also crucial, with analgesics such as acetaminophen or ibuprofen recommended for mild to moderate pain, and short-term opioids considered for severe pain.
Antibiotics and Follow-up
Antibiotics are generally not required unless the patient has systemic symptoms, immunosuppression, or significant cellulitis. If needed, broad-spectrum antibiotics like amoxicillin-clavulanate 875/125 mg orally twice daily for 5-7 days may be prescribed 1. Follow-up appointments should be scheduled within 1-2 weeks to assess healing and check for signs of fistula formation. If healing is delayed or drainage persists, evaluation for an underlying fistula using imaging or examination under anesthesia is recommended.
Key Considerations
- The role of wound packing after anorectal abscess drainage remains unproven, and its use should be left to individual unit policy and patient discussion 1.
- Sampling of drained pus is suggested in high-risk patients, those with risk factors for multidrug-resistant organism infection, or in cases of recurrent infections or non-healing wounds 1.
- The choice of imaging investigation should take into account patient’s past medical history, clinical presentation, local availability of resources, and skills 1.
By following this approach, patients with perianal abscesses can receive effective treatment and reduce the risk of complications, improving their overall morbidity, mortality, and quality of life.
From the Research
Management of Perianal Abscess
The management of perianal abscess involves several approaches, including:
- Incision and drainage of the abscess with or without treatment of anal fistula 2
- Fistulotomy and fistulectomy to reduce the recurrence rate of fistula-in-ano and perianal abscess 3, 4
- Management without general anesthesia, which can be effective in infants less than 24 months old 5
- Incision and drainage alone, without packing of the abscess cavity, which can be a safe and effective treatment option 6
Treatment Outcomes
The outcomes of these treatment approaches include:
- Reduced recurrence or persistence of abscess/fistula, or the need for repeat surgery 2
- Low risk of incontinence following fistula surgery with abscess drainage 2
- High success rate of management without general anesthesia in infants less than 24 months old 5
- Similar healing times, analgesic requirements, pain scores, abscess recurrence, and fistula rates with or without packing of the abscess cavity 6
Considerations
When managing perianal abscess, it is essential to consider the following:
- The presence of a fistula-in-ano, which can increase the risk of abscess recurrence 2, 3, 4
- The potential for incontinence following fistula surgery with abscess drainage, although this risk is generally low 2
- The need for individualized treatment approaches, taking into account the patient's age, medical history, and other factors 3, 5