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Perianal Abscess

Perianal abscess is a simple type of anorectal abscess characterized by collection of purulent material on the skin surface surrounding the anus. It arises from the cryptoglandular epithelium of the anal canal.


Presentation

The most common manifestations of abscesses are pain and swelling in the perianal region. Occasionally discharge of pus can be noted from the abscess. Infection is characterized by fever, redness, swelling, and pain. Patients often complain of perianal discomfort and pruritus. When the abscess open link spreads to perianal space, induration, erythema, or fluctuance may occur. But the symptoms may not be prominent as the region has abundant subcutaneous tissue. Movement or pressure at the perianal region, as in sitting or defecation, may aggravate pain. When the abscess spreads to ischiorectal region, fever, chill and severe perirectal pain may develop as symptoms. Pain at defecation may result in constipation.

Fever
  • RESULTS: Epidural abscess was suspected because the patient had a fever and intense low back pain following drainage of a perianal abscess.[ncbi.nlm.nih.gov]
  • When the abscess spreads to ischiorectal region, fever, chill and severe perirectal pain may develop as symptoms. Pain at defecation may result in constipation.[symptoma.com]
  • The pain lasted seven days and there was no evidence of fever. Bacterial examination of tissue of the infiltrate discovered Staphylococcus aureus. Angiocentric T-cell lymphoma was demonstrated on biopsy.[ncbi.nlm.nih.gov]
  • The patient had a short history of painless perineal induration without fever or leucocytosis with normal routine blood tests.[ncbi.nlm.nih.gov]
  • He has a fever of 39 C. On exam a palpable mass is felt at the anal verge.[step2.medbullets.com]
Malaise
  • The infection can cause fever and malaise, while the pain involved with having a bowel movement can result in constipation. People of any age can develop perianal abscesses, including infants and toddlers still in diapers.[livestrong.com]
  • […] related to the fistula include Discharge of pus for an opening near the anus (discharge may relieve the pain) Pain and discomfort in the anal region Irritation of skin around the anus Passing some blood with the discharge Fever Feeing poorly in general (malaise[colorectalcentre.co.uk]
  • Deeper abscesses may be less painful but cause toxic symptoms (eg, fever, chills, malaise). There may be no perianal findings, but digital rectal examination may reveal a tender, fluctuant swelling of the rectal wall.[msdmanuals.com]
  • […] throbbing, and worse when sitting down Skin irritation around the anus, including swelling, redness, and tenderness Discharge of pus Constipation or pain associated with bowel movements Deeper anal abscesses may also be associated with: Fever Chills Malaise[webmd.com]
Constitutional Symptom
  • The wall of the abscess is made up of dermis infiltrated with inflammatory cells surrounded by a fibrinous capsule. [1] Fevers, chills, and other constitutional symptoms are usually absent unless the infection has spread to deep tissues or into the bloodstream[emedicine.medscape.com]
Perineal Pain
  • A 61-year-old man was admitted to our hospital complaining of perineal pain and was found to have a perianal abscess. He was diabetic but had not received treatment for the disease.[ncbi.nlm.nih.gov]
Familial Adenomatous Polyposis
  • PURPOSE: This study examines the risk factors for developing perianal abscess or fistula formation after ileal pouch-anal anastomosis procedure for chronic ulcerative colitis or familial adenomatous polyposis.[ncbi.nlm.nih.gov]
Constipation
  • One had constipation and one was incontinent during the night. CONCLUSIONS: Simple drainage of a perianal abscess is followed frequently by a fistula.[ncbi.nlm.nih.gov]
  • Pain during bowel movements may lead to constipation. Abscesses that are deeper lead to fever and chills. A physical examination of the rectal region is sufficient to diagnose abscesses in the anal region.[symptoma.com]
  • The infection can cause fever and malaise, while the pain involved with having a bowel movement can result in constipation. People of any age can develop perianal abscesses, including infants and toddlers still in diapers.[livestrong.com]
  • You will also be given laxatives to avoid constipation and the discomfort it could cause. The amount of time lost from work is usually minimal.[bowelandkeyholeclinic.com]
Rectal Pain
  • Snap Shot A 45-year-old man has severe rectal pain when he defecates. He has a fever of 39 C. On exam a palpable mass is felt at the anal verge.[step2.medbullets.com]
  • Symptoms of an abscess include anal or rectal pain, itching, swelling, and fever. Frequently the abscess results in a fistula, which is an abnormal connection between the abscess and the skin where pus drains.[fairview.org]
  • Patients may present with fever, chills, and rectal pain. An area of erythema, induration, and tenderness with possible fluctuance is present within the buttock.[journals.lww.com]
  • You may also have rectal pain and a fever. If you can see the abscess on the skin, it is usually red, swollen, and tender when touched. Care: Tests: You may need one or more of the following tests to help care givers plan your treatment.[drugs.com]
Abdominal Pain
  • pain, or chronic diarrhea.[fairview.org]
  • High pelvirectal abscesses may cause lower abdominal pain and fever without rectal symptoms. Sometimes fever is the only symptom.[msdmanuals.com]
  • Symptoms of an anal abscess include: A detectable painful lump in the anal region Painful bowel movements Lower abdominal pain Swelling in anal area or buttocks Drainage of pus from a pimple on the buttocks Systemic signs such as fever or malaise There[lacolon.com]
  • pain Fatigue Swelling in the anal area or buttocks Night sweats When to Seek Medical Care for an Anal Abscess If a person suspects they have a perirectal or perianal abscess they should see a healthcare professional.[emedicinehealth.com]
Rectal Discharge
  • It causes extreme pain, fatigue , rectal discharge, and fever . In some cases, anal abscesses can result in painful anal fistulas. This occurs when the abscess doesn’t heal and breaks open on the surface of the skin.[healthline.com]
  • It causes extreme pain, fatigue, rectal discharge, and fever. In some cases, anal abscesses can result in painful anal fistulas. This occurs when the abscess doesn’t heal and breaks open on the surface of the skin.[healthline.com]
  • discharge, pain, or other symptoms of anorectal abscess Have fever, chills, or other new symptoms after being treated for this condition Are a diabetic and your blood glucose becomes difficult to control Prevention or prompt treatment of STDs may prevent[medlineplus.gov]
  • discharge, pain, or other symptoms of anorectal abscess Have fever, chills, or other new symptoms after being treated for this condition Are a diabetic and your blood glucose becomes difficult to control Prevention Prevention or prompt treatment of STDs[pennstatehershey.adam.com]
Anal or Rectal Pain
  • Symptoms of an abscess include anal or rectal pain, itching, swelling, and fever. Frequently the abscess results in a fistula, which is an abnormal connection between the abscess and the skin where pus drains.[fairview.org]
Low Back Pain
  • RESULTS: Epidural abscess was suspected because the patient had a fever and intense low back pain following drainage of a perianal abscess.[ncbi.nlm.nih.gov]
Pelvic Pain
  • Diffuse pelvic pain and raised body temperature are found occasionally. Besides physical examination, including rectal-digital examination, CT, MRI or endosonography have proven to give information about deeper abscesses (grade B and C).[ncbi.nlm.nih.gov]

Workup

Physical examination along with clinical history of the patient help in the diagnosis of perianal abscesses. Anorectal observation is often performed in the office or emergency department. Physical examination may reveal indurated area adjacent to anus. Anesthesia is required only in case of intersphincteric and supralevator abscesses. Presence of other anorectal abscesses may be confirmed with the help of laboratory tests. Specific laboratory tests are not indicated otherwise in case of perianal abscesses. WBC count may be elevated. Imaging techniques are generally not used unless the abscesses are complicated. Anal ultrasonography is occasionally used to diagnose anorectal abscesses. As it causes considerable discomfort, it is not used in case of intersphincteric and supralevator abscesses. Culture of the content from the abscess is sometimes recommended in case of recurrent anorectal abscess. Infection-causing pathogen can be identified using microbiological culture methods. The contents are stained to check for acid-fast bacilli. Microscopic examination of the content would help to rule out tuberculosis. Differential diagnosis include anal fissure, thrombosed hemorrhoid, pilonidal abscess, infected epidermoid inclusion cyst, perianal hidradenitis suppurativa, and sexually transmitted diseases. Radiological studies are not helpful in the diagnosis of this condition.
Risk factors like history of Crohn’s disease should be considered. Perianal pain usually begins one to two days before the presentation and it may gradually become more severe [6]. They may complain of swelling and warmth of the tissues surrounding anus. Coughing, sneezing and bowel movements often increase the pain. Rectal bleeding may not be reported unless there is spontaneous drainage.

Treatment

Draining the abscess without delay helps to prevent it from spreading into a necrotizing, soft-tissue infection [9]. This may further lead to life-threatening sepsis. Perianal abscesses can be drained externally using local anesthesia. If the abscesses develop into intersphincteric or supralevator abscesses, general anesthesia may be needed for anal examination and drainage. It is usually drained into the anal canal and rectum [10]. The wound should be cleaned thoroughly with warm water, 2 to 3 times daily after drainage. Warm water bath is recommended for cleansing after bowel movements. If there is drainage, absorbent dressings are used to prevent staining. More fiber should be included in the diet to prevent the formation of hard stools.
There is no standard antibiotic regime for the control of abscesses. Broad-spectrum antibiotics are often given preoperatively and discontinued one day after surgery. Generally, penicillin or cephalosporin is given in combination with clindamycin, ciprofloxacin, or metromidazole. If necrotizing soft tissue infection is present, more aggressive surgical intervention is recommended.
In most of the cases, the symptoms show considerable improvement if abscess is adequately drained. If the abscess is not completely drained, re-examination is suggested to ensure that the abscess is fully drained. For those who have recurrent abscesses, examination by general surgeon would help to rule out the possibility of fistula as the underlying cause. Other risk factors like HIV, immunosuppression, and TB also should be excluded.

Prognosis

Mortality due to anorectal abscesses in general, and perianal abscesses in specific, is very low [6]. About 50% of the patients develop fistulas [7]. Recurrence is reported in 10% of the patients with perianal abscesses. One of the studies showed that 37% of the patients with abscesses develop recurrent sepsis [8]. About two thirds of the patients who have spontaneous drainage or are treated by incision, develop chronic fistula, and about 43% of the patients develop fecal incontinence after surgical intervention for treating fistula. Post-operative urinary retention and post-ejaculation urethral irritation are also reported as complications.

Etiology

Anal abscesses are caused by infection or obstruction of the anal cryptal glands [2]. Abscesses may be formed by aerobic or anaerobic bacteria, including Bacteroides fragilis, Peptostreptococcus, Fusobacterium, and Clostridium. Aerobic forms like Staphylococcus aureus, Streptococcus and Escherichia coli also are known to infect anal glands [3]. The cryptal glands may become obstructed by the accumulation of debris, allowing the growth of bacteria.
Some other common causes of anorectal abscesses include

Epidemiology

Although occurrence of anal abscesses is very common, and majority of the patients with perianal abscesses may not report or seek medical help for treatment. Prevalence of perianal abscesses may thus be more common than clinical reports. Further, any anorectal discomfort or condition is often attributed to hemorrhoids. This makes prevalence estimation of specific anorectal abscesses difficult. In United States about 100,000 new cases of anorectal abscesses are reported every year [1]. About 30% of the patients have a history of abscesses. Many of them resolve without any specific treatment or surgical intervention. Incidence of anorectal abscesses is more in the age group of 30-40 years [4]. Abscesses are reported from children also, but is mostly mild and may not require any form of surgical intervention [5]. Anorectal abscesses like perianal abscesses are more common in men when compared to women [4]. No significant differences are noted in the occurrence of abscesses in different parts of the world. Some theories suggest a direct relation between development of anorectal abscesses and bowel habits. It is presumed that diarrhea and poor personal hygiene increase the chances of developing abscesses. The incidence of abscesses was found to be higher in spring and summer.

Sex distribution
Age distribution

Pathophysiology

About 90% of the anorectal abscesses arise from obstruction of cryptal glands in anus [2]. Glandular secretions accumulate allowing infection that leads to suppuration and formation of abscesses. Abscess formation usually starts in the intersphincteric space and then gradually spreads to the neighboring tissues. Infected fluid usually collects at the terminal region of the gland. Abscess increases in size and follow the path of least resistance, spreading to the surface. This results in perianal abscess. In some cases it may spread to ishiorectal fossa or to the region above levator muscles, forming ischiorectal abscess and supralevator abscesses, respectively. In about 37% of the patients, perianal abscesses are associated with anal fistulas. If not drained, perianal abscess may recur.

Prevention

There is no standard method or guideline to prevent perianal abscesses. Protection from sexually transmitted diseases is key in preventing the development of abscesses. Good personal hygiene is equally important for adults and children to protect from perianal abscesses. Having more fiber in the food helps to prevent the formation of hard stools, one of the important risk factor in the development of anal abscesses.

Summary

Perianal abscess is a simple type of anorectal abscess characterized by collection of purulent material on the skin surface surrounding the anus. It arises from the cryptoglandular epithelium of the anal canal. It may extend from the intersphincteric groove to the perianal skin. Perianal abscess occurs in the form of a tender mass on the surface of the skin and represents a more chronic form of suppuration when compared to other forms of anorectal abscesses [1]. Draining the abscess prevents it from spreading to the nearby tissues like ischiorectal space or supralevator space. This will also help to prevent it from developing into a systemic infection. Perianal and ischiorectal abscesses are the common forms of anal abscesses found among the general population. Surgical incision and drainage are the most common treatment recommended.

Patient Information

Perianal abscess is a collection of pus outside the anus. It can cause pain, and in addition, fatigue and fever. In some cases the abscess may break open or fail to heal, resulting in the formation of fistula. Perianal abscesses require immediate medical attention to prevent it from developing into more complicated, and life-threatening situations. Perianal abscesses often develop from an obstruction or infection of the glands in the anus. As the glands plug up with debris, secretions accumulate in the gland allowing bacterial infection. These may burst releasing the contents causing abscesses in the space surrounding rectum or anus. Occasionally abscess may enlarge leading to fever, and causing difficulty in bowel movements. Certain factors increase the risk of developing perianal abscesses. This includes diabetes, HIV, Crohn’s disease, low immunity, pregnancy, presence of foreign bodies in the anus, sexually transmitted disease, and anal fissures.
Many people with anal abscesses do not seek medical attention for treatment. Prevalence of different types of anal abscesses are not known because of this reason. It is most commonly seen in men in the age group of 30-40 years. In infants, abscesses are generally mild and may not need drainage or any other surgical intervention. Incidence of abscesses are more common in spring and summer. Some of the most common symptoms of perianal abscess include pain in the perianal area, pus collection near the anus, fever, pain during bowel movements, and fatigue. Pain during bowel movements may lead to constipation. Abscesses that are deeper lead to fever and chills. A physical examination of the rectal region is sufficient to diagnose abscesses in the anal region. For deeper abscesses, other tests and imaging techniques may be recommended.
If left untreated, anal abscesses may develop into painful anal fistulas. Draining the pus from the infected area is the most common treatment method. Drainage is usually done in the clinic or emergency room under local anesthesia. Surgery is suggested for large abscesses. The abscesses after drainage is left open for healing. Warm baths, 2 to 3 times a day, is recommended after drainage. Sitting in warm water for some time helps to reduce swelling and also in additional drainage, if needed. Antibiotics may be recommended before the surgery and continued for one day after drainage. Food rich in fiber is very important to prevent formation of hard stool. Diabetic patients may have to stay back in the hospital for monitoring infections. Good hygiene, cleanliness and protection from sexually transmitted diseases are very important in preventing anal abscesses. Occasionally abscesses may recur and some patients. In general, outcome is very good after drainage.

References

Article

  1. Abcarian H. Anorectal infection: Abscess-fistula. Clinics in colon and rectal surgery 2011. 24:14.
  2. Rizzo JA, Naig AL, Johnson EK. Anorectal abscess and fistula-in-ano: evidence-based management. Surg Clin North Am 2010; 90:45.
  3. Brook I, Frazier EH. The aerobic and anaerobic bacteriology of perirectal abscesses. J Clin Microbiol. 1997;35(11):2974-6.
  4. Beard JM, Osborn J. Anorectal Abscess. In: Rakel RE, Rakel DP, eds. Textbook of Family Medicine. 8th ed. Philadelphia, Pa: Saunders; 2011.
  5. Novotny NM, Mann MJ, Rescorla FJ. Fistula in ano in infants: who recurs?. Pediatr Surg Int. 2008;24(11):1197-9.
  6. Marcus RH, Stine RJ, Cohen MA. Perirectal abscess. Ann Emerg Med. May 1995;25(5):597-603.
  7. Hämäläinen KP, Sainio AP. Incidence of fistulas after drainage of acute anorectal abscesses. Dis Colon Rectum. 1998;41(11):1357-1361.
  8. Hamadani A, Haigh PI, Liu IL, Abbas MA. Who is at risk for developing chronic anal fistula or recurrent anal sepsis after initial perianal abscess?. Dis Colon Rectum. 2009;52(2):217-221.
  9. Adinolfi MF, Voros DC, Moustoukas NM, Hardin WD, Nichols RL. Severe systemic sepsis resulting from neglected perineal infections. South Med J. 1983;76(6):746-9.
  10. Prasad ML, Read DR, Abcarian H. Supralevator abscess: diagnosis and treatment. Dis Colon Rectum. 1981;24(6):456-61.

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Last updated: 2018-06-22 07:37