What is the treatment for a buttocks abscess?

Treatment of Buttocks Abscess

Incision and drainage is the cornerstone of treatment for all buttocks abscesses, ideally performed within 24 hours of presentation. 1

Diagnosis and Initial Assessment

• Clinical diagnosis is usually sufficient for typical buttocks abscesses, though imaging may be considered for atypical presentations or suspected complex cases 1
• CT scan is the preferred imaging modality when needed due to its short acquisition time and widespread availability 1, 2
• Ultrasound can be particularly useful for identifying septations within the abscess with higher sensitivity (81-88%) and specificity (83-96%) than CT 2

Surgical Management

• Incision and drainage is the primary treatment for buttocks abscesses, with timing based on patient condition 1, 2
• Emergency drainage is indicated for patients with:
  • Sepsis or septic shock
  • Immunosuppression
  • Diabetes mellitus
  • Diffuse cellulitis 1
• For non-emergent cases, drainage should ideally be performed within 24 hours 1
• The incision should be kept as close as possible to the anal verge (for perianal abscesses) to minimize potential fistula length while ensuring adequate drainage 1
• Complete drainage is essential, as inadequate drainage is associated with high recurrence rates 1, 2

Specific Drainage Techniques

• For simple abscesses, standard incision and drainage with gentle curettage is recommended 1, 3
• For thick, viscous abscess contents that are difficult to drain, consider:
  • Using a larger incision
  • More thorough curettage
  • Possible surgical consultation for complex cases 2
• Needle aspiration alone is insufficient therapy for skin abscesses, with success rates of only 26% compared to 80% for incision and drainage 4

Post-Procedure Care

• The role of wound packing after abscess drainage remains controversial 1
• Some evidence suggests packing may be costly and painful without adding benefit to healing, though packing wounds larger than 5 cm may reduce recurrence and complications 1, 3
• Warm soaks and appropriate analgesia should be provided for post-procedure comfort 5

Antibiotic Therapy

• Antibiotics are not routinely indicated after adequate surgical drainage of uncomplicated abscesses 1, 5
• Consider antibiotics only in cases of:
  • Sepsis or surrounding soft tissue infection
  • Compromised immune response
  • High-risk patients (immunosuppressed, diabetic) 1
• When antibiotics are needed, they should be effective against common causative organisms including Staphylococcus aureus (including MRSA) and anaerobes 4, 5

Follow-Up and Recurrence Prevention

• Routine imaging after incision and drainage is not required 1
• Consider follow-up imaging in cases of:
  • Recurrence
  • Suspected inflammatory bowel disease
  • Evidence of fistula or non-healing wound 1
• Risk factors for recurrence include:
  • Inadequate drainage
  • Loculations within the abscess
  • Horseshoe-type abscess
  • Delayed time from disease onset to incision 1, 2

Special Considerations

• For abscesses with concomitant fistulas, perform fistulotomy only for low fistulas not involving sphincter muscle; place a loose draining seton for fistulas involving sphincter muscle 1
• MRSA infections may have lower success rates with both incision and drainage (61%) and needle aspiration (8%) compared to non-MRSA infections 4
• Complex or recurrent abscesses may require specialist consultation and more aggressive management 2