Incision and Drainage Procedure Steps
For perianal abscesses, perform incision and drainage as close to the anal verge as possible while ensuring complete drainage, avoiding sphincter damage, and using local anesthesia for small simple abscesses in fit patients without sepsis. 1, 2
Pre-Procedure Assessment
- Verify the patient is appropriate for outpatient I&D: young, fit, immunocompetent, no diabetes, no systemic sepsis signs (fever, tachycardia, hypotension), and no extensive cellulitis 2, 3, 4
- Refer immediately to surgery if: sepsis/severe sepsis present, immunocompromised, diabetic, diffuse cellulitis, horseshoe abscess, or multiple loculations 2, 3, 4
- Position the patient appropriately: prone position for sacrococcygeal abscesses with buttocks separated using adhesive tape 5
Anesthesia Administration
- Inject local anesthetic (1% lidocaine) directly into the surrounding tissue using standard infiltration technique 6, 7
- Alternative technique for sacrococcygeal abscesses: aspirate abscess contents first, then inject the same volume of local anesthetic into the abscess cavity through the same needle to minimize pain from multiple injections 5
- Provide systemic analgesia as needed for patient comfort during the procedure 7
Incision Technique
- Make the incision as close to the anal verge as feasible to minimize potential fistula tract length if one develops 1, 2
- For large abscesses, use multiple counter-incisions rather than a single long incision to avoid step-off deformity and delayed healing 2
- Ensure the incision is surgically appropriate and large enough to allow complete drainage without injuring vital structures 7
- For perianal and ischioanal abscesses: incise through overlying skin 1, 2
- For intersphincteric abscesses: drain into the rectal lumen with possible limited internal sphincterotomy 1, 2
- For supralevator abscesses: drain via rectal lumen (if extension of intersphincteric abscess) or externally via skin (if extension of ischioanal abscess) 1, 2
Drainage and Cavity Management
- Perform complete drainage of all abscess contents as inadequate drainage leads to recurrence rates up to 44% 1, 2
- Break up loculations gently using a finger or instrument to ensure all pockets are drained 7
- Perform gentle curettage of the abscess cavity if needed 5
- Do NOT probe for fistulas during acute abscess drainage as this causes iatrogenic complications 4
Post-Drainage Wound Management
- Omit wound packing as evidence suggests it is costly, painful, and does not improve healing 1, 2, 4
- If packing is used per institutional protocol: remove within 24 hours 8
- Alternative to packing: place a catheter or drain into the cavity that drains to external dressing, though this remains controversial 1
Fistula Management (If Identified)
- For low fistulas not involving sphincter muscle: perform fistulotomy at time of drainage 1, 2
- For fistulas involving any sphincter muscle: place a loose draining seton only 1, 2
Post-Procedure Care
- Prescribe warm soaks for wound care 8, 7
- Provide systemic analgesia as needed 7
- Antibiotics are NOT routinely indicated after adequate drainage 2, 7
- Use antibiotics only if: sepsis present, surrounding soft tissue infection/cellulitis, immunocompromised patient, or incomplete source control 2, 3
- When antibiotics are indicated: use empiric broad-spectrum coverage for Gram-positive, Gram-negative, and anaerobic bacteria as these are polymicrobial infections 2
Follow-Up
- Schedule close follow-up to monitor for recurrence 7
- Routine imaging is NOT required unless recurrence occurs, inflammatory bowel disease suspected, or non-healing wound present 2, 4
Common Pitfalls to Avoid
- Never perform simple I&D for: necrotizing fasciitis, gas gangrene, deep organ/space infections, or abscesses near vital structures 3
- Do not underestimate abscess extent: refer to surgery if complex anatomy or multiple loculations suspected 4
- Avoid inadequate incision size: this is the primary cause of treatment failure and recurrence 1, 2