From the Guidelines
The treatment for perianal abscesses primarily involves surgical drainage, which should be performed promptly to relieve pain and prevent complications, as recommended by the most recent guidelines 1. The procedure typically includes incision and drainage under local anesthesia, with the abscess cavity left open to heal by secondary intention. Antibiotics are not routinely needed for uncomplicated perianal abscesses after drainage, but may be prescribed in specific situations such as extensive cellulitis, systemic symptoms, immunocompromised patients, or diabetics, as suggested by 1 and 1. When antibiotics are necessary, options include amoxicillin-clavulanate 875/125 mg twice daily, trimethoprim-sulfamethoxazole DS twice daily, or clindamycin 300-450 mg four times daily for 5-7 days. Prevention focuses on good perianal hygiene, including:
- Gentle cleansing with mild soap and water after bowel movements
- Avoiding harsh soaps or vigorous scrubbing
- Keeping the area dry Sitz baths (warm water soaks) for 10-15 minutes several times daily can help with healing after drainage and prevent recurrence. For patients with recurrent abscesses, evaluation for underlying conditions like inflammatory bowel disease, diabetes, or HIV may be warranted, as mentioned in 1. Approximately 30-50% of perianal abscesses are associated with fistula formation, which may require additional surgical intervention by a colorectal specialist if identified. It's worth noting that the role of oral antibiotic therapy alone versus surgical drainage for small abscesses is still unknown, as stated in 1, but surgical drainage is generally recommended as the primary treatment, as supported by 1 and 1.
From the Research
Treatment of Perianal Abscesses
- The primary treatment for perianal abscesses is surgical drainage, as it is essential to control perianal sepsis 2, 3, 4, 5.
- Antibiotic therapy may be considered in addition to surgical drainage to prevent the development of anal fistulas, with studies suggesting a potential benefit in reducing fistula formation 2, 6, 3, 4.
- The use of antibiotics such as ciprofloxacin and metronidazole has been investigated, with some studies showing a significant protective effect against fistula formation 3, 4.
Prevention of Perianal Abscesses and Fistulas
- There is evidence to suggest that postoperative antibiotic therapy, including ciprofloxacin and metronidazole, may play a role in preventing fistula in-ano formation after incision and drainage of perianal abscesses 3, 4.
- A 7-10 day course of postoperative antibiotics may be advised after incision and drainage of perianal abscesses to prevent fistula formation, although the quality of evidence is low and further randomized trials are needed 3, 4.
- Routine operative swab cultures and post-operative antibiotic use for uncomplicated perianal abscesses may be unnecessary, as they rarely impact subsequent management and outcomes 5.