Treatment of Perineal Cysts Between the Testicles and Anus

The primary treatment for a perineal cyst (anorectal abscess) located between the testicles and anus is surgical incision and drainage. 1

Diagnosis and Assessment

A focused medical history and complete physical examination, including digital rectal examination, should be performed to confirm the diagnosis of a perineal cyst 1
Laboratory tests should be considered in patients with systemic signs of infection or sepsis, including complete blood count, serum creatinine, and inflammatory markers (C-reactive protein, procalcitonin) 1
In patients with suspected diabetes, serum glucose, hemoglobin A1c, and urine ketones should be checked 1
Imaging studies are generally not required for typical presentations but may be helpful in complex cases:
- CT scan, MRI, or endoanal ultrasound may be considered for atypical presentations, suspected deep abscesses (supralevator or intersphincteric), or when there is suspicion of underlying conditions like Crohn's disease 1
- Point-of-care transperineal ultrasound is emerging as a diagnostic tool but is highly operator-dependent 1

Incision and drainage is the definitive treatment for perineal cysts/abscesses 1
The timing of surgery should be based on the presence and severity of sepsis 1
For small perianal abscesses in immunocompetent patients without systemic signs of sepsis, outpatient management may be considered 1
Surgical principles:
- The incision should be kept as close as possible to the anal verge to minimize the length of a potential fistula 1
- Complete drainage is essential to prevent recurrence, which can be as high as 44% with inadequate drainage 1
- The specific surgical approach depends on the anatomical location of the cyst/abscess:
  - Perianal and ischioanal abscesses should be drained via incision of the overlying skin 1
  - Intersphincteric abscesses should be drained into the rectal lumen and may require limited internal sphincterotomy 1
  - Supralevator abscesses may require drainage via the rectal lumen or externally via the skin depending on their origin 1

For epididymal cysts specifically (if that is the type of perineal cyst in question), percutaneous sclerotherapy using 3% Polidocanol may be considered as an alternative to surgery, with reported success rates of 84% 2
For simple testicular cysts, observation alone may be appropriate for asymptomatic cases, while symptomatic cysts may require local parenchyma-sparing excision 3
For large testicular cysts (>6 cm), more aggressive surgical approaches including orchiectomy may be necessary in some cases 4

Antibiotic therapy is not routinely recommended for simple, uncomplicated abscesses after adequate drainage 1
Antibiotics should be administered in the following situations:
- Presence of systemic signs of infection or sepsis 1
- Immunocompromised patients 1
- Incomplete source control 1
- Significant surrounding cellulitis 1
When indicated, empiric broad-spectrum antibiotic therapy should cover Gram-positive, Gram-negative, and anaerobic bacteria 1

Routine imaging after incision and drainage is usually not required 1
Follow-up imaging should be considered in cases of:
- Recurrence 1
- Suspected inflammatory bowel disease 1
- Evidence of a fistula or non-healing wound 1

High recurrence rates (up to 44%) emphasize the importance of complete drainage 1
Risk factors for recurrence include inadequate drainage, loculations, horseshoe-type abscess, and delayed treatment 1
For epididymal cysts specifically, microscopic surgical techniques may reduce complications such as scrotal hematoma, edema, and long-term postoperative pain 5
Early intervention for epididymal cysts (before reaching 0.8 cm in diameter) may prevent destruction of epididymal tubules 5