What is the treatment for a 2x2 cm abscess at the buttock with a single punctum that is firm?

Treatment of 2x2 cm Buttock Abscess with Single Punctum

This abscess requires incision and drainage as the primary treatment, which can be performed in an outpatient setting if the patient is immunocompetent and has no systemic signs of sepsis. 1

Primary Treatment Approach

Incision and drainage is the definitive treatment for this abscess. 1 The surgical approach should include:

• Make the incision as close as possible to the anal verge (if perianal) or directly over the abscess to minimize potential fistula tract length while ensuring adequate drainage 1, 2
• Thoroughly evacuate all purulent material and probe the cavity to break up any loculations to reduce the 44% recurrence rate associated with inadequate drainage 1, 2
• Examine for an associated fistula tract during the procedure - if a low subcutaneous fistula not involving sphincter muscle is identified, fistulotomy can be performed at the same time 2

Setting and Timing

For a fit, immunocompetent patient with a 2x2 cm abscess without systemic signs of sepsis, outpatient management under local anesthesia is appropriate. 1 However, drainage should be performed urgently if any of the following are present:

• Signs of sepsis or systemic infection 1
• Immunosuppression or diabetes mellitus 1
• Diffuse surrounding cellulitis 1

Wound Management

Packing is optional for this size abscess. 1 The evidence shows:

• No definitive recommendation can be made regarding packing based on available literature 1
• Research suggests that omitting packing is safe and effective, avoiding the pain of packing removal 3
• Simply covering with a dry dressing is usually adequate 4
• For abscesses >5 cm, packing may reduce recurrence 5

Antibiotic Therapy

Antibiotics are NOT routinely indicated after adequate surgical drainage in an immunocompetent patient without systemic signs of infection. 1, 2

Antibiotics ARE indicated if:

• Systemic signs of infection or sepsis are present 1, 2, 4
• Significant surrounding cellulitis exists 2, 4
• The patient is immunocompromised 2, 4
• Source control is incomplete 2, 4

When antibiotics are needed, use empiric broad-spectrum coverage for Gram-positive, Gram-negative, and anaerobic bacteria for 4-7 days. 2, 4

Pre-Procedure Evaluation

Before drainage, assess for:

• Diabetes screening (serum glucose, hemoglobin A1c, urine ketones) to identify undetected diabetes mellitus 1
• Complete blood count, inflammatory markers (CRP, procalcitonin, lactate) if systemic infection is suspected 1
• Digital rectal examination to assess for deeper extension 1

Imaging Considerations

Imaging is NOT routinely required for a straightforward 2x2 cm superficial buttock abscess. 1 Consider CT, MRI, or endosonography only if:

• Atypical presentation 1
• Suspicion of deep supralevator abscess 1, 2
• Suspected inflammatory bowel disease 1, 2
• Complex anal fistula suspected 1

Follow-Up

Close follow-up is essential given the high recurrence rate (up to 44%) 1, 2:

• Monitor for recurrence or fistula development 2
• Risk factors for recurrence include inadequate drainage, loculations, and delayed treatment 1
• Routine imaging after drainage is not required unless there is recurrence, suspected IBD, or non-healing wound 1, 2

Common Pitfalls to Avoid

• Do NOT probe for fistulas if none is obvious - this can cause iatrogenic complications 1
• Ensure complete drainage - inadequate drainage is the leading cause of recurrence 1
• Avoid unnecessarily long incisions - multiple counter incisions are preferred for larger abscesses to prevent delayed healing 2, 4