Management of Recurrent Perianal Abscess with Fistula
The most appropriate step is D - Examination under general anesthesia (EUA) with immediate surgical drainage, which should not be postponed even if imaging is unavailable. 1, 2
Immediate Surgical Drainage is Mandatory
When a perianal abscess is clinically suspected with fluctuation present, EUA with drainage must be performed urgently and should not be delayed for imaging studies. 1, 2 The presence of a fluctuant mass on examination confirms a collection requiring surgical drainage, which is the cornerstone of treatment for all perianal abscesses. 2
Why Other Options Are Inappropriate:
CT pelvis (Option A) delays definitive treatment and is unnecessary when clinical examination already confirms an abscess requiring drainage. 1, 2 Imaging before drainage is only recommended when the diagnosis is uncertain or for complex disease mapping after the acute sepsis is controlled. 3
Oral antibiotics with outpatient follow-up (Option B) is inadequate because antibiotics alone cannot treat an abscess—surgical drainage is mandatory. 2 Antibiotics are not routinely indicated after adequate surgical drainage unless sepsis, significant cellulitis, or immunosuppression is present. 4, 2
Bedside needle aspiration (Option C) is insufficient for perianal abscesses, which require formal incision and drainage under anesthesia to ensure complete evacuation and proper assessment. 1, 2
Critical Management Principles During EUA
During acute abscess drainage, do not actively probe for the fistula tract to avoid creating iatrogenic tracts that complicate future management. 2 If an obvious fistula is identified without probing, place a loose draining seton rather than performing fistulotomy. 2
Never attempt definitive fistulotomy during acute abscess drainage to preserve anal sphincter function and minimize tissue disruption. 2 The incision should be made as close to the anal margin as possible to minimize the length of any potential fistula. 4
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. 2 This recurrent pattern mandates evaluation for underlying Crohn's disease after the acute phase resolves. 1, 2
After controlling the acute sepsis, perform endoscopic evaluation of the rectum to determine the most appropriate long-term management strategy, as the presence of proctitis significantly affects fistula healing rates. 1, 2 The presence of perianal fistulas with recurrent abscesses should raise suspicion for Crohn's disease, which occurs in 13.7-37% of CD patients. 4, 3
Post-Operative Management
Following EUA and drainage, the patient should be counseled that definitive fistula management will require subsequent treatment planning after acute sepsis resolves. 2 If Crohn's disease is identified, the treatment strategy includes seton drainage followed by anti-TNF therapy (particularly infliximab) after adequate surgical drainage. 4, 3
Routine imaging after drainage is not required unless there is recurrence, suspected inflammatory bowel disease, or evidence of non-healing wound. 2 However, given the recurrent nature of this patient's disease, contrast-enhanced pelvic MRI should be obtained after the acute phase to assess for complex fistula anatomy and guide definitive management. 3
Common Pitfalls to Avoid
- Do not delay surgical drainage for imaging studies when clinical examination confirms an abscess. 1, 2
- Do not rely on antibiotics alone—they cannot adequately treat an established abscess collection. 4, 2
- Do not perform aggressive fistula surgery during acute abscess drainage, as this increases complications and incontinence risk. 2, 5
- Do not assume simple cryptoglandular disease in recurrent cases—always evaluate for underlying Crohn's disease. 4, 2