What is the recommended procedure for abscess drainage?

Abscess Drainage Procedure

Incision and drainage is the cornerstone of treatment for all abscesses, with the technique varying based on abscess location to ensure complete drainage while minimizing complications. 1

General Principles of Abscess Drainage

• The incision should be kept as close as possible to the anal verge (for perianal abscesses) or appropriate anatomical location to minimize potential fistula length while ensuring adequate drainage 2, 1
• Complete drainage is essential, as inadequate drainage is associated with high recurrence rates (up to 44%) 2, 1
• Risk factors for recurrence include inadequate drainage, loculations, horseshoe-type abscess, and delayed time from disease onset to incision 2

Specific Drainage Techniques by Abscess Location

• Perianal and ischioanal abscesses: Drain via incision and drainage of the overlying skin 2, 1
• Intersphincteric abscesses: Drain into the rectal lumen; a limited internal sphincterotomy may be required 2, 1
• Supralevator abscesses: Drain via the rectal lumen (if extension of an intersphincteric abscess) or externally via the skin (if extension of ischioanal abscess) 2, 1

Timing of Drainage Procedure

• Emergency drainage is indicated for patients with:
  • Sepsis, severe sepsis, or septic shock 2, 1
  • Immunosuppression 2
  • Diabetes mellitus 2
  • Diffuse cellulitis 2, 1
• In the absence of these factors, surgical drainage should ideally be performed within 24 hours 2, 1

Anesthesia for Abscess Drainage

• Young, fit patients without signs of sepsis may have surgery in an ambulatory setting 2
• Small simple perianal abscesses may be treated under local anesthesia 2
• Injectable lidocaine provides effective analgesia for incision and drainage of skin abscesses 3
• Alternative techniques such as aspiration followed by injection of anesthetic into the abscess cavity can reduce pain associated with multiple infiltrations 4

Management of Concomitant Fistulas

• If an obvious fistula is found during abscess drainage:
  • Perform fistulotomy only for low fistulas not involving sphincter muscle (i.e., subcutaneous fistula) 2, 1
  • Place a loose draining seton for fistulas involving any sphincter muscle 2, 1
• Avoid probing to search for a possible fistula to prevent iatrogenic complications 2

Post-Drainage Wound Care

• The role of wound packing after abscess drainage remains controversial 2, 1
• Common practice includes placing an internal dressing (pack) into the cavity for hemostasis and to prevent premature closure of the skin 2
• Recent evidence suggests packing may be costly and painful without adding benefit to the healing process 2, 1
• Some practitioners place a catheter or drain into the abscess cavity with a small stab incision under local anesthetic, leaving it in place until drainage stops 2
• For larger wounds (>5 cm), packing may reduce recurrence and complications 5

Antibiotic Therapy

• Antibiotics are not routinely indicated after adequate surgical drainage 1
• Consider antibiotics only in cases of sepsis, surrounding soft tissue infection, disturbances of immune response, or high-risk patients 1

Follow-Up Care

• Routine imaging after incision and drainage is not required 1
• Consider follow-up imaging in cases of recurrence, suspected inflammatory bowel disease, or evidence of fistula or non-healing wound 1
• Warm soaks and appropriate analgesia are important components of postoperative care 6