What is the appropriate treatment for a patient with a painful, fluctuating mass in the right gluteal area, presenting with warmth, redness, and tenderness?

Appropriate Treatment for Gluteal Abscess

The appropriate treatment is incision and drainage (option c), as this painful, fluctuating mass with warmth, redness, and tenderness represents a cutaneous abscess that requires surgical drainage for definitive management. 1

Clinical Reasoning

Why Incision and Drainage is the Definitive Treatment

• Fluctuation is the key clinical finding that indicates a collection of pus requiring surgical drainage rather than antibiotics alone 1
• The 2018 WSES/SIS-E consensus guidelines state that complex skin and subcutaneous abscesses are typically well circumscribed and respond to incision and drainage 1
• Effective treatment of abscesses entails incision, thorough evacuation of the pus, and probing the cavity to break up loculations 1
• The gluteal region is considered a complex abscess site due to its anatomic location and potential for polymicrobial infection 1

Why Other Options Are Inadequate

Ultrasound (option a):

• Imaging is not necessary when clinical examination clearly demonstrates a fluctuant abscess 1
• The physical findings (warmth, redness, tenderness, fluctuation) are sufficient for diagnosis 1

Needle aspiration (option b):

• Simple aspiration is inadequate because it does not allow for breaking up loculations or ensuring complete drainage 1
• Abscesses require probing of the cavity to prevent recurrence 1

Oral antibiotics and follow-up (option d):

• Antibiotics alone cannot adequately drain a formed abscess 1
• Gram stain, culture, and systemic antibiotics are rarely necessary for simple cutaneous abscesses 1

When to Add Antibiotics to Surgical Drainage

The 2018 WSES guidelines recommend antibiotic therapy only in specific circumstances 1:

• Systemic signs of infection are present (fever, tachycardia, hypotension) 1
• Immunocompromised patients (HIV, diabetes, malignancy, neutropenia) 1
• Source control is incomplete after drainage 1
• Significant surrounding cellulitis extends beyond the abscess 1

Antibiotic Selection if Needed

• For gluteal abscesses, empiric broad-spectrum coverage should include Gram-positive, Gram-negative, and anaerobic bacteria 1
• The gluteal region can harbor polymicrobial flora including anaerobes due to proximity to the perineum 1
• Staphylococcus aureus is present as a single pathogen in only approximately 25% of cutaneous abscesses 1

Surgical Technique Essentials

• Make a surgically appropriate incision that allows adequate drainage without creating step-off deformities 1
• Large abscesses should be drained with multiple counter incisions rather than one long incision 1
• Pack the wound with moist dressings or place drains for at least 5-7 days 1, 2
• Simply covering the surgical site with a dry dressing is usually the easiest and most effective treatment 1

Critical Pitfalls to Avoid

• Do not miss deeper pathology: In the gluteal region, consider gluteal compartment syndrome if there is extensive swelling, altered mental status, or signs of muscle necrosis 3
• Rule out injection-related complications: Gluteal abscesses can result from intramuscular injections causing hematoma formation and subsequent infection 4
• Ensure adequate drainage: Inadequate drainage can lead to spread of infection and bacteremic complications 5
• Do not assume simple infection: Persistent systemic symptoms after drainage should prompt evaluation for endocarditis or other deep-seated infections 1

Postoperative Management

• Warm soaks to promote continued drainage 5
• Systemic analgesia as needed 5
• Close follow-up within 24-48 hours to ensure adequate drainage and wound healing 5
• Drainage or wicks should remain in place for at least 5-7 days 2