What is the treatment for a recurrent gluteal abscess?

Treatment of Recurrent Gluteal (Butt) Abscess

For recurrent gluteal/perianal abscesses, the primary treatment is repeat incision and drainage with complete evacuation of all pus and loculations, followed by investigation for an underlying fistula tract and consideration of definitive fistula management to prevent further recurrence. 1

Immediate Surgical Management

Primary Intervention

• Perform incision and drainage as the cornerstone of treatment for any recurrent abscess, as this is non-negotiable regardless of recurrence status 1, 2
• The incision should be placed as close as possible to the anal verge to minimize potential fistula tract length while ensuring adequate drainage and avoiding sphincter damage 1
• Complete drainage is absolutely essential - inadequate drainage is the leading cause of recurrence, with rates as high as 44% when drainage is incomplete 1, 2
• Thoroughly evacuate all pus and actively probe the cavity to break up any loculations, as loculations are a specific risk factor for recurrence 1, 2

Timing Considerations

• Emergency drainage (immediate) is required if the patient has sepsis, severe sepsis, septic shock, immunosuppression, diabetes mellitus, or diffuse cellulitis 1, 2
• In the absence of these high-risk features, surgical drainage should ideally be performed within 24 hours 1, 2

Investigation for Underlying Fistula

Why This Matters for Recurrence

• Approximately one-third of perianal abscesses have an associated fistula-in-ano, which dramatically increases recurrence risk 1, 3
• The fact that this is a recurrent abscess significantly raises suspicion for an underlying fistula tract that was not addressed during initial treatment 1

Imaging for Recurrent Cases

• For recurrent abscesses, imaging follow-up is specifically recommended to identify fistula tracts or non-healing wounds 1, 2
• MRI is the gold standard for evaluating fistula tracts with 76-100% accuracy, particularly if Crohn's disease is suspected 2
• CT scan offers advantages of short acquisition time and widespread availability for initial assessment 2

Fistula Management at Time of Drainage

• If an obvious fistula is identified during drainage, perform immediate fistulotomy ONLY for low fistulas not involving sphincter muscle (subcutaneous fistulas) 1, 2
• For any fistula involving sphincter muscle, place a loose draining seton rather than performing fistulotomy to avoid incontinence risk 1, 2
• Do NOT probe or use hydrogen peroxide to search for a fistula if not obvious, as this causes iatrogenic complications 1
• Evidence shows that treating the fistula at the time of abscess drainage reduces recurrence by 87% (RR=0.13), though this must be balanced against a non-significant trend toward incontinence 3

Antibiotic Therapy

Indications for Antibiotics

• Antibiotics are indicated for recurrent abscesses when there is:
  • Sepsis or systemic signs of infection 1, 2
  • Surrounding soft tissue infection or significant cellulitis 1
  • Immunocompromised state or disturbances of immune response 1, 2
  • Inadequate source control despite drainage 1

Antibiotic Selection

• Use empiric broad-spectrum coverage targeting Gram-positive (including MRSA), Gram-negative, and anaerobic bacteria 1
• These abscesses are frequently polymicrobial in origin 1
• Consider obtaining pus cultures in recurrent cases or high-risk patients, as MRSA prevalence can be as high as 35% in anorectal abscesses 1

Duration

• A 5-10 day course of antibiotics following drainage may reduce fistula formation by 36% in patients with surrounding cellulitis or systemic sepsis 1

Post-Operative Management

Wound Packing

• The role of wound packing remains controversial and cannot be strongly recommended 1
• Evidence suggests packing may be costly and painful without adding benefit to healing 1, 2
• If packing is used, it should be removed within 24 hours and changed regularly until cavity heals 1

Follow-Up Strategy

• Re-evaluate at 7 days - persistent fever or failure to improve indicates inadequate source control requiring repeat imaging or intervention 4
• For recurrent cases specifically, follow-up imaging is recommended to assess for fistula tracts or non-healing wounds 1, 2

Special Considerations for Recurrence

Risk Factors to Address

The following factors increase recurrence risk and must be actively managed 1, 2:

• Inadequate drainage - ensure complete evacuation
• Loculations - must be broken up during drainage
• Horseshoe-type abscess - requires multiple counter incisions rather than one long incision
• Delayed time from disease onset to incision - emphasizes need for prompt treatment

Underlying Conditions to Investigate

• Consider inflammatory bowel disease (especially Crohn's disease) in patients with recurrent perianal/gluteal abscesses 1, 2
• If Crohn's disease is suspected, endoscopic assessment of the rectum should be performed, as proctitis predicts persistent non-healed fistula tracts 2
• Rule out diabetes mellitus in all patients with recurrent abscesses 1

Common Pitfalls to Avoid

• Do not perform simple needle aspiration - this has a 41% recurrence rate compared to 15% with proper incision and drainage 1
• Do not create one long incision for large abscesses - use multiple counter incisions to avoid step-off deformity and delayed healing 1
• Do not blindly probe for fistulas if not clinically obvious, as this causes iatrogenic injury 1
• Do not perform fistulotomy on high fistulas involving sphincter muscle at initial drainage, as this risks incontinence 1