From the Guidelines
Surgical drainage is the primary treatment for a hemorrhoidal abscess, and it should be performed as soon as possible, ideally within 24 hours, to minimize the risk of complications and promote healing. The procedure involves making a small incision to release the pus, and it is usually performed under local anesthesia in an outpatient setting 1.
Post-Drainage Care
Following drainage, patients can benefit from:
- Warm sitz baths (sitting in warm water) for 10-15 minutes, 2-3 times daily, to help with healing and pain relief
- Pain management with acetaminophen (Tylenol) 500-1000mg every 6 hours or ibuprofen (Advil, Motrin) 400-600mg every 6-8 hours as needed
- Stool softeners like docusate sodium (Colace) 100mg twice daily to prevent constipation that might worsen pain
- Increased fiber intake (25-30g daily) and drinking plenty of water (8-10 glasses daily) to help maintain soft stools
Antibiotic Use
Antibiotics are sometimes prescribed if there's significant surrounding infection, typically a broad-spectrum option like amoxicillin-clavulanate (Augmentin) 875/125mg twice daily for 7-10 days 1.
Importance of Prompt Treatment
Prompt treatment is essential as untreated abscesses can develop into fistulas (abnormal connections between the anal canal and skin), which require more complex treatment 1. Recurrent abscesses may indicate an underlying condition requiring further evaluation.
Non-Operative Management
For patients with complicated hemorrhoids, non-operative management with dietary and lifestyle changes (i.e., increased fiber and water intake together with adequate bathroom habits) is recommended as the first-line therapy 1.
Key Considerations
- The primary treatment of anorectal abscesses, including hemorrhoidal abscesses, remains surgical drainage, with the timing being dictated by the severity and nature of any sepsis 1
- The risk factors associated with recurrence are inadequate drainage, loculations, horseshoe-type abscess, and time from disease onset to incision 1
- A complete and accurate drainage of the abscess is crucial to minimize the risk of recurrence 1
From the Research
Definition and Symptoms of Hemorrhoidal Abscess
- A hemorrhoidal abscess is a complication of hemorrhoidal disease, which causes extreme pain, likely resulting from internal anal sphincter hypertonicity, leading to congestion and swelling 2.
- The most common symptom of hemorrhoids is rectal bleeding associated with bowel movement, and hemorrhoidal size, thrombosis, and location determine the extent of pain or discomfort 3, 4.
Treatment Options for Hemorrhoidal Abscess
- The choice of treatment for external hemorrhoidal thrombosis (EHT) remains controversial, and both conservative and surgical options have been proposed 2.
- Conservative treatment options include wait and see, mixture of flavonoids, mix of lidocaine and nifedipine, botulinum toxin injection, and topical application of 0.2% glyceryl trinitrate 2.
- Surgical treatments are recommended when EHT fails to respond to conservative management or when symptoms onset falls within the last 48-72 hours, and include drainage with radial incision, conventional excision, excision under local anesthesia, and stapled technique 2.
Postoperative Care for Hemorrhoidectomy
- Warm sitz bath is routinely recommended after anal surgery, but a study found that it does not reduce symptoms in the posthaemorrhoidectomy period, including pain scores, analgesic requirements, and patient satisfaction ratings 5.
- However, another study found that using a sitz bath with ozonised water reduced pain and accelerated healing in patients who have had a haemorrhoidectomy, compared to using a sitz bath with ordinary tap water 6.
Management of Hemorrhoidal Abscess
- The management and treatment of EHT is still controversial, and no specific guidelines have been published, but both medical and surgical treatment have been proven effective 2.
- Randomized clinical trials and structured consensus-based guidelines are warranted to determine the best course of treatment for hemorrhoidal abscess 2.