I have a rapidly enlarging perianal abscess and imaging isn’t available until tomorrow night at 7 p.m.; should I wait for imaging and have the surgeon schedule immediate incision‑and‑drainage, or go to the emergency department now for same‑day drainage with anesthesia?

Go to the Emergency Department Now for Immediate Drainage

You should go to the emergency department immediately rather than waiting until tomorrow evening for imaging—a rapidly enlarging perianal abscess requires urgent surgical drainage, and delaying treatment increases your risk of complications, recurrence, and systemic infection. 1, 2

Why Immediate Drainage Takes Priority

• Imaging is not required before drainage when a perianal abscess is clinically obvious. Clinical diagnosis alone is sufficient for typical perianal abscesses, and delaying drainage to obtain imaging can allow the infection to extend into adjacent spaces and progress to systemic infection. 3, 1

• Emergency drainage is specifically indicated for rapidly enlarging abscesses because this suggests aggressive infection that could lead to sepsis, and the presence of sepsis, severe sepsis, or septic shock mandates emergency drainage within hours, not days. 1, 2

• Inadequate or delayed drainage is the principal cause of abscess recurrence, with recurrence rates up to 44% when drainage is insufficient or delayed. 1

Addressing Your Anesthesia Concerns

• Emergency departments routinely perform perianal abscess drainage under anesthesia. The procedure is typically done under local anesthesia with or without procedural sedation in the ED, or under general/regional anesthesia in the operating room depending on abscess complexity and patient factors. 4

• You can request anesthesia/sedation in the ED. Most emergency departments can provide procedural sedation (conscious sedation) for perianal abscess drainage, which makes the procedure comfortable while still allowing same-day treatment. 4

• If the abscess is large or complex, the ED surgeon will arrange for OR drainage under general anesthesia rather than attempting inadequate bedside drainage—so you won't be forced into an uncomfortable procedure without proper anesthesia. 4

What Will Happen in the Emergency Department

• The ED team will perform immediate incision and drainage as the primary treatment, keeping the incision as close as possible to the anal verge to minimize potential fistula length while ensuring complete drainage. 1, 2

• If imaging is needed to assess for deeper collections or complexity, the ED can obtain a CT scan immediately (within hours, not waiting until tomorrow evening), as CT offers advantages of short acquisition time and widespread availability for emergency assessment. 1, 5

• The surgical team will examine you under anesthesia during drainage to identify any deeper abscess components or fistulous openings, which are present in roughly one-third of cases but cannot be detected by external examination alone. 1, 5

Why Waiting Until Tomorrow Evening Is Risky

• A 24+ hour delay allows the abscess to expand into adjacent spaces (potentially creating horseshoe or supralevator extensions) and increases the risk of systemic infection requiring more extensive surgery. 1, 2

• Delayed time from disease onset to incision is a documented risk factor for recurrence, meaning waiting makes it more likely you'll need repeat surgery later. 1

• If you develop fever, increasing pain, or signs of systemic infection while waiting, you would need emergency drainage anyway—so going now prevents this deterioration. 2, 6

The Role of Imaging (If Any)

• Imaging after drainage is only needed if there's suspicion of residual collections, inflammatory bowel disease, or non-healing wounds—not as a prerequisite before initial drainage. 1

• If the ED team suspects a complex abscess (horseshoe-type, multiloculated, or supralevator extension) based on clinical examination, they will obtain immediate CT imaging to guide complete drainage, but this happens in the ED setting, not as an outpatient delay. 1, 5

Common Pitfalls to Avoid

• Do not wait for scheduled outpatient imaging when you have a rapidly enlarging abscess—this is the exact scenario that requires urgent intervention. 3, 1

• Do not accept inadequate drainage or overly small incisions if the procedure is performed—inadequate drainage is the leading cause of 44% recurrence rates and should be avoided. 1

• Do not delay seeking care if you develop fever, increasing pain, or systemic symptoms—these indicate progression to sepsis requiring emergency drainage. 2, 6