Is packing recommended after incising and draining an abscess?

From the Guidelines

Packing after draining an abscess is not recommended as its use remains unproven and may cause additional pain and healthcare expense. The decision to pack should be based on individual unit policy and patient discussion, as recent evidence suggests that smaller, uncomplicated abscesses may heal effectively without packing, potentially with less pain and fewer follow-up visits 1. When considering packing, it is essential to weigh the potential benefits against the potential drawbacks, including increased pain and cost, as noted in a multi-center observational study that found packing to be costly and painful without adding benefit to the healing process 1. The primary treatment of anorectal abscesses remains surgical drainage, with the timing being dictated by the severity and nature of any sepsis, and the incision should be kept as close as possible to the anal verge to minimize the length of a potential fistula, while still providing adequate drainage and avoiding sphincteral damage 1.

Some key points to consider when managing anorectal abscesses include:

• The primary treatment is surgical drainage, with timing based on the presence and severity of sepsis 1
• The incision should be kept close to the anal verge to minimize potential fistula length 1
• Packing may not be necessary for small, uncomplicated abscesses, and its use should be individualized 1
• Signs of healing include decreased pain, reduced redness, and diminishing drainage, while increasing pain, spreading redness, fever, or purulent discharge may indicate complications requiring medical attention 1.

It is crucial to prioritize the patient's clinical condition, comorbidities, and individual factors when making decisions about packing and other aspects of anorectal abscess management, as emphasized in the WSES-AAST guidelines 1.

From the Research

Packing After Incising and Draining an Abscess

• The evidence on whether packing is recommended after incising and draining an abscess is mixed and limited by the quality of the studies 2, 3, 4, 5, 6.
• A study published in 2016 found that it is unclear whether continued post-operative packing of the cavity of perianal abscesses affects time to complete healing, and the evidence was downgraded to very low quality due to risk of bias and imprecision 2.
• Another study from 1992 found that calcium alginate was less painful to remove and easier to remove than gauze dressings, suggesting that it may be a better option for packing abscess cavities 3.
• A 2013 study found that the use of a silver-containing hydrofiber dressing to pack abscess cavity after incision and drainage led to faster wound healing and less pain compared to standard care with iodoform 4.
• A pilot randomized controlled trial published in 2015 found that healing could be achieved safely without packing, and that the non-packing group had less pain and faster healing times compared to the packing group 5.
• A 2022 review article suggests that packing wounds larger than 5 cm may reduce recurrence and complications, but notes that wound culture and antibiotics do not improve healing 6.

Key Findings

• The use of calcium alginate or silver-containing hydrofiber dressings may be associated with less pain and easier removal compared to traditional gauze dressings 3, 4.
• The evidence on the effectiveness of packing for reducing recurrence and complications is limited, but some studies suggest that it may be beneficial for larger wounds 6.
• The decision to pack an abscess cavity after incision and drainage may depend on individual patient factors and local practices, as the evidence is not sufficient to support a universal recommendation 2, 5.