What is the recommended procedure for incision and drainage of a simple abscess?

Incision and Drainage of Simple Abscess Procedure Note

Pre-Procedure Assessment

Perform incision and drainage under local anesthesia for simple subcutaneous abscesses in immunocompetent patients without systemic signs of sepsis. 1, 2

Patient Selection Criteria

• Appropriate candidates: Young, fit patients without significant comorbidities, no immunosuppression, no diabetes, and no systemic sepsis signs (fever, tachycardia, hypotension) 2
• Refer to surgery immediately if: Patient has sepsis/septic shock, immunocompromised status, diabetes mellitus, extensive cellulitis beyond the abscess, or complex anatomy (horseshoe abscess, multiple loculations) 2, 3

Pre-Procedure Considerations

• Clinical diagnosis is usually sufficient for typical abscesses; imaging is not routinely needed unless atypical presentation or suspected deep extension 3
• Exclude perianal/pilonidal location requiring special considerations, inflammatory bowel disease, or post-operative abscesses 4

Anesthesia Technique

Use local anesthetic infiltration around the abscess, or consider aspiration-injection technique for sacrococcygeal abscesses to minimize pain. 5

Standard Approach

• Infiltrate local anesthetic around the abscess perimeter, avoiding injection directly into the infected cavity 6
• Consider systemic analgesia (acetaminophen or ibuprofen) for patient comfort 1

Alternative Technique (Sacrococcygeal)

• Position patient prone with buttocks separated using adhesive tape 5
• Aspirate abscess contents with needle, then inject equal volume of local anesthetic into the cavity through the same needle 5
• This eliminates multiple painful infiltrations and reduces anesthetic volume required 5

Incision Technique

Make an incision large enough to ensure complete drainage, as inadequate drainage leads to recurrence rates up to 44%. 1, 2, 3

Incision Placement

• For perianal/pilonidal abscesses: Keep incision as close to the anal verge as possible to minimize potential fistula length while ensuring adequate drainage 2, 3
• For other locations: Make incision over the point of maximum fluctuance 6
• Minimally invasive approach: Consider small incisions (rather than traditional large cruciate incisions) with vessel loop drainage, which shows comparable outcomes with fewer complications and better patient compliance 7

Drainage Procedure

• Break up loculations with gentle finger exploration or blunt instrument to ensure complete drainage 6
• Perform gentle curettage of the cavity if needed 5
• Critical pitfall: Do NOT probe for fistulas during acute abscess drainage, as this causes iatrogenic complications 2

Wound Management

Do not routinely pack wounds, as evidence shows packing causes additional pain without improving healing time. 1, 4

Packing Decision

• No packing: Safe and effective for most subcutaneous abscesses, eliminates painful removal 1, 4
• Consider packing only: For wounds larger than 5 cm, where it may reduce recurrence 8
• If packing is placed, remove within 24 hours 1

Wound Closure

• Allow wound to heal by secondary intention—do not allow skin edges to close prematurely 1

Post-Procedure Instructions

Wound Care

• Keep wound clean and dry initially 1
• Begin warm water soaks or sitz baths 24-48 hours after procedure to promote drainage and healing 1

Pain Management

• Prescribe over-the-counter acetaminophen or ibuprofen as needed 1
• Advise patient that pain should progressively improve over the first week; increasing pain indicates recurrence or inadequate drainage 1

Activity Restrictions

• Avoid strenuous activity for 48-72 hours to prevent bleeding or wound disruption 1

Antibiotic Management

Antibiotics are NOT routinely needed after adequate drainage. 1, 3

Indications for Antibiotics

• Fever >38.5°C (101.3°F) 1
• Diabetes, immunosuppression, or other immune system problems 1
• Surrounding cellulitis extending beyond the immediate abscess area 2, 3
• Sepsis or systemic signs of infection 3

Culture

• Wound cultures do not improve healing and are not routinely indicated 8

Follow-Up and Warning Signs

Return Precautions

• Immediate return if: Fever >38.5°C (101.3°F), rapidly spreading redness, or increasing pain/swelling/pus after initial improvement 1

Follow-Up Care

• Routine imaging is NOT needed after drainage unless abscess recurs or fails to heal 1, 3
• Recurrence occurs in 15-44% of cases, particularly with inadequate initial drainage 1, 2
• For anorectal abscesses, up to one-third may have underlying fistula tract increasing recurrence risk 1

Risk Factors for Recurrence

• Inadequate drainage, loculations, horseshoe-type abscess, and delayed treatment 2, 3