What is the most appropriate management step for a patient with a history of recurrent perianal abscesses, presenting with a tender mass, redness, and a fistula with fluctuation in the perianal area, and normal abdominal examination?

Management of Recurrent Perianal Abscess with Fistula

The most appropriate management is D - Examination under general anesthesia with surgical drainage, as this patient has a fluctuant perianal abscess that requires immediate operative intervention regardless of imaging availability. 1

Immediate Surgical Drainage is Mandatory

• Examination under anesthesia (EUA) with drainage should not be postponed even if pelvic imaging is unavailable when a perianal abscess is clinically suspected. 1
• The presence of fluctuation indicates a collection requiring surgical drainage, which is the cornerstone of treatment for all perianal abscesses. 1, 2
• The timing should be based on sepsis severity: emergent for sepsis/immunosuppression/diabetes/cellulitis, otherwise within 24 hours. 1, 2

Why Other Options Are Inappropriate

CT pelvis (Option A) is incorrect because imaging should not delay drainage when an abscess is clinically evident with fluctuation and redness. 1 While CT may have a role in atypical presentations or suspected complex disease, this patient has clear clinical findings requiring immediate surgical intervention. 1

Oral antibiotics with outpatient follow-up (Option B) is incorrect because antibiotics are not routinely indicated after adequate surgical drainage and cannot substitute for drainage of a fluctuant abscess. 2 Antibiotics should only be considered for sepsis, surrounding soft tissue infection, or immunocompromised patients - not as primary treatment. 2

Bedside needle aspiration (Option C) is incorrect because it has unacceptably high recurrence rates (41% versus 15% for incision and drainage) and provides inadequate drainage. 1 Complete drainage is essential, as inadequate drainage is the primary risk factor for recurrence in this patient who already has recurrent presentations. 1

Critical Management Principles During EUA

• Do not actively probe for the fistula during acute abscess drainage. 1 Over-vigorous attempts to find a fistula may create iatrogenic tracts and complicate future management. 1

• If an obvious fistula is identified without probing, place a loose draining seton rather than laying it open. 1 The seton should be low-profile, soft material, avoiding bulky knots or firm sutures like nylon. 1

• Never attempt fistulotomy during acute abscess drainage to minimize tissue disruption and preserve anal function. 1

• Keep the incision as close as possible to the anal verge to minimize potential fistula length while ensuring adequate drainage. 1, 2

Special Considerations for Recurrent Disease

• The history of recurrent presentations with spontaneous drainage strongly suggests underlying fistula-in-ano, which occurs in approximately one-third of perianal abscess cases. 1

• Exclude underlying Crohn's disease in every patient with recurrent anorectal abscess. 1 Endoscopic evaluation of the rectum should be performed after the acute phase to determine the most appropriate long-term management strategy. 1

• Risk factors for recurrence include inadequate drainage, loculations, horseshoe-type abscess, and delayed time from onset to incision. 1, 2

Post-Operative Management

• Routine imaging after drainage is not required unless there is recurrence, suspected inflammatory bowel disease, or evidence of non-healing wound. 1

• Antibiotics are not routinely needed after adequate surgical drainage unless sepsis or significant cellulitis is present. 2

• The patient should be counseled that definitive fistula management will require subsequent treatment planning after the acute sepsis resolves, potentially including sphincter-sparing procedures. 1