What is the treatment for a perirectal abscess?

From the Guidelines

The primary treatment for a perirectal abscess is surgical drainage, which should be performed promptly to prevent complications. This involves making an incision over the abscess, evacuating the pus, and leaving the wound open to heal by secondary intention 1. The procedure is typically done under local anesthesia for small abscesses or general anesthesia for larger or deeper ones. Following drainage, patients should take sitz baths 2-3 times daily and keep the area clean. Pain management typically includes acetaminophen or NSAIDs, with stronger medications like oxycodone reserved for severe pain.

Key Considerations

• Antibiotics are not routinely needed after drainage unless the patient has systemic symptoms (fever, elevated white blood cell count), immunosuppression, diabetes, or valvular heart disease 1.
• When antibiotics are indicated, options include amoxicillin-clavulanate 875/125 mg twice daily, trimethoprim-sulfamethoxazole DS twice daily, or ciprofloxacin 500 mg plus metronidazole 500 mg, all for 5-7 days.
• Patients should follow up within 1-2 weeks to ensure proper healing and to evaluate for fistula formation, which occurs in about 30-50% of cases and may require additional surgical intervention.

Imaging Investigations

• Imaging investigations such as MRI, CT scan, or endosonography may be used in cases of atypical presentation, suspicion of occult supralevator abscesses, complex anal fistula, or perianal Crohn’s disease 1.
• The choice of imaging investigation should take into account patient’s past medical history, clinical presentation, local availability of resources, and skills.

Post-Operative Care

• No recommendation can be made regarding the use of packing after drainage of an anorectal abscess, based on the available literature 1.
• Patients should be advised to keep the area clean and take sitz baths 2-3 times daily to promote healing.

Special Considerations

• In fit, immunocompetent patients with a small perianal abscess and without systemic signs of sepsis, outpatient management may be considered 1.
• The timing of surgery should be based on the presence and severity of sepsis, with emergent drainage indicated in cases of sepsis, severe sepsis, or septic shock 1.

From the Research

Treatment for Perirectal Abscess

The treatment for perirectal abscess typically involves:

• Incision and drainage (I&D) of the abscess, which is the primary treatment approach 2, 3
• The use of antibiotics, which may be recommended in conjunction with I&D to reduce the risk of recurrence and improve patient outcomes 2, 4
• In some cases, endoscopic ultrasound-guided transrectal drainage may be considered as a minimally invasive alternative to conventional surgical drainage techniques 5

Factors Associated with Treatment Outcomes

Several factors can influence treatment outcomes for perirectal abscess, including:

• Adequacy of antibiotic coverage, with inadequate coverage associated with a higher risk of recurrence 2
• Patient demographics and comorbidities, such as age, sex, and underlying medical conditions 3
• The presence of underlying conditions, such as Crohn's disease, which can increase the risk of complications and recurrence 5

Alternative Treatment Approaches

Alternative treatment approaches, such as primary curative incision, have been proposed to reduce the risk of postoperative fistula formation and recurrent abscess 6

• However, more research is needed to fully evaluate the effectiveness and safety of these alternative approaches.

Key Considerations

Key considerations in the treatment of perirectal abscess include:

• The need for prompt and adequate drainage to reduce the risk of complications and recurrence
• The importance of antibiotic therapy in reducing the risk of recurrence and improving patient outcomes
• The potential benefits and risks of alternative treatment approaches, such as endoscopic ultrasound-guided transrectal drainage and primary curative incision.