Continuing Education Activity

Perianal abscesses are the most common type of anorectal abscesses. These abscesses can cause significant discomfort for patients. They are located at the anal verge and if left untreated, can extend into the ischioanal space or intersphincteric space since these areas are continuous with the perianal space. They can also cause systemic infection if left untreated. This activity reviews the pathophysiology of perianal abscess and highlights the role of the interprofessional team in its management.

Objectives:

• Describe the pathophysiology of perianal abscess.
• Review the presentation of perianal abscess.
• Outline the treatment and management options available for perianal abscess.
• Describe interprofessional team strategies for improving care coordination and outcomes in patients with perianal abscess.

Introduction

Perianal abscesses are the most common type of anorectal abscesses. These abscesses can cause significant discomfort for patients. They are located at the anal verge and, if left untreated, can extend into the ischioanal space or intersphincteric space since these areas are continuous with the perianal space. They can also cause systemic infection if left untreated.[1][2]

Etiology

Ninety percent of all anorectal abscesses are caused by non-specific obstruction and subsequent infection of the glandular crypts of the rectum or anus. A perianal abscess is a type of anorectal abscess that is confined to the perianal space. Other causes can include inflammatory bowel diseases such as Crohn's disease, as well as trauma, or cancerous origins. Patients with recurrent or complex abscesses should be evaluated for Crohn's disease.[1][3][4][3]

Epidemiology

The prevalence of perianal abscesses and anorectal abscesses, in general, are underestimated, since most patients do not seek medical attention, or are dismissed as having symptomatic hemorrhoids.  The mean age at presentation is 40 years old, and adult males are twice as likely as females to develop an abscess.[5][6] Risk factors include anything that causes immunosuppression or poor wound healing such as smoking, HIV, immunosuppressive drugs, and diabetes. Crohn's disease is also a known risk factor for developing a perirectal abscess.[7]

Pathophysiology

On presentation, patients will typically complain of severe pain in the anal area, which has generally been present for several days. This is due to an infection of the anal glands, which are not adequately draining through the anal crypts. The anal glands empty into ducts that traverse the internal sphincter and drain into the anal crypts at the level of the dentate line. If not adequately draining, infection of these glands will form an abscess that can spread along several planes, such as the perianal or perirectal spaces. The perianal space surrounds the anus and is continuous with the fat of the buttock. Once a fluid collection forms, it can spread along the path of least resistance, which is typically into the intersphincteric space and other potential spaces such as the supralevator space or ischiorectal space.[8][9]

Aerobic and anaerobic organisms are responsible for these abscesses, including Bacteroides fragilis, Peptostreptococcus, Prevotella, Fusobacterium, Porphyromonas, Clostridium species, Staphylococcus aureus, Streptococcus, and Escherichia coli.[10]

History and Physical

A detailed history and physical examination are pertinent to every patient and maybe all that is necessary to make a diagnosis. Patients will complain of anal pain, which may be dull, sharp, aching, or throbbing. This may be accompanied by fever, chills, constipation, or diarrhea. Patients with perianal abscess typically present with pain around the anus, which may or may not be associated with bowel movements, but is usually constant. Purulent discharge may be reported if the abscess is spontaneously draining, and blood per rectum may also be reported in a spontaneously draining abscess.

A physical exam can typically rule out other causes of anal pain, such as hemorrhoids. It will yield an area of fluctuance or an area of erythema and induration in the skin around the perianal area. Cellulitis should be noted and marked if extending beyond the fluctuant area. For follow-up purposes, it should be noted whether the patient has diabetes, and their blood sugar on routine fingerstick should also be noted.

Evaluation

A physical exam is typically the only requirement for diagnosis. The digital rectal exam should be performed and may yield a fluctuant mass. Cellulitis may extend beyond the fluctuant area and should be marked. Computed tomography or MRI may be used in the setting of clinical suspicion without signs discussed above, especially in the setting of unexplained significant anorectal pain, and in the immunocompromised patient who may not mount an immune response. MRI is the preferred method of imaging as a CT scan may miss small abscesses in the immunocompromised patients. Anorectal ultrasound may be used however it is not tolerated well secondary to pain.[11][12][13]

Laboratory testing will usually reveal an elevated white blood cell count. However, the absence of a leukocytosis should not deter the physician from the appropriate treatment of an abscess, namely surgical drainage.

Treatment / Management

Perianal abscesses are an indication for timely incision and drainage. Antibiotic administration alone is inadequate and inappropriate. Once incision and drainage are performed, there is no need for antibiotic administration unless certain medical issues necessitate the use. Such conditions include valvular heart disease, immunocompromised patients, diabetic patients, or in the setting of sepsis. Antibiotics are also considered in these patients or cases with signs of systemic infection or significant surrounding cellulitis.[1][14]

Incision and drainage are typically performed in the clinic setting or immediately in the emergency department. Local anesthesia with 1% lidocaine may be administered to the surrounding tissues. A cruciate incision is made as close to the anal verge as possible to shorten any potential fistula formation. Blunt palpation is used to ensure no other septation or abscess pocket is missed. Before completing the procedure, it is useful to excise a skin flap of the cruciate incision or the tips of the four skin flaps to ensure adequate drainage and prevent premature healing of the skin over the abscess pocket. Packing may be placed initially for hemostasis. Continual packing may be further utilized for healing by secondary intention. Patients are encouraged to keep the incision and drainage site clean. Sitz baths may assist in pain relief.

More extensive abscesses may require the operating room for the adequate exam under anesthesia to ensure adequate drainage and inspect for other diseases such as fistula in ano.[1]

Differential Diagnosis

The differential diagnosis for a perianal abscess includes anal trauma, anal fissure, anal fistula, thrombosed external hemorrhoid, pilonidal cyst, buttocks abscess, cellulitis, Crohn’s disease, ulcerative colitis, malignancy, proctitis, HIV/ AIDS, other sexually transmitted diseases, Bartholin’s abscess, and hidradenitis suppurativa.

Prognosis

With appropriate and prompt drainage mortality from a perirectal abscess is very low. However, in immunocompromised patients, those with Crohn's, or those where the abscess is detected late and has progressed to a potentially deadly condition such as Fournier's gangrene mortality and morbidity can be significant[15][16]. Additionally, the morbidity even in healthy patients can be significant with approximately one-third of patients developing a fistula secondary either to the disease process itself or the surgical drainage.[17]

Complications

• Sepsis
• Recurrent abscess
• Fistula formation (either secondary to the disease process itself or surgical intervention)
• Fecal incontinence (either secondary to the disease process itself or surgical intervention)[18]

Postoperative and Rehabilitation Care

After treatment, the patient needs pain control, laxatives or fiber supplements to avoid constipation, and instructions on properly performing sitz baths.

Outpatient antibiotics are rarely indicated but should be considered if the patient demonstrates signs of systemic infection such as fevers or high leukocytosis. Cultures and sensitivities of the causative organism are rarely helpful.[19]

Because of a high recurrence rate, all patients need to be followed up until there is complete healing, which may take up to 8 weeks. Additionally, up to one-third of patients may either already have a fistula in ano or develop one after their abscess, which is another reason to have a close follow-up. If there is a recurrent abscess, further evaluation is needed for potential Crohn's HIV, neoplasm, or other underlying etiology.

Consultations

Perirectal abscesses often require surgical drainage even if they have ruptured or are already training. Therefore a general or colorectal surgeon should be consulted to evaluate the patient. Alternatively, an ED physician may perform the drainage procedure themselves.

If the abscess is recurrent or complicated, then a work-up for Crohn's disease or HIV should be performed with appropriate consultations to gastroenterology or an HIV management team as needed.

Deterrence and Patient Education

There are few effective strategies to prevent perianal abscess in an otherwise healthy patient. Keeping the perianal area clean and dry to avoid skin breakdown can be helpful. High fiber diets may theoretically reduce the chance of anal gland blockage, but there is no real evidence to confirm that as an effective treatment. If the patient has an underlying etiology such as Crohn's or HIV, then treatment of that condition can help reduce the risk of developing a perianal abscess.

Pearls and Other Issues

Horseshoe perianal abscesses are uncommon. They are abscesses that surround the entire anus. These abscesses are typically drained through an incision, and drainage is performed posterior to the anus. It is helpful to place counter incisions at the anterior extent of the abscess to ensure adequate drainage. Penrose may be placed through these incisions to aid in continued drainage and prevent premature closure. These drains are left in place for 2 to 3 weeks and then removed in the post-operative office visit.

Prompt follow-up with surgical services is advisable to monitor wound healing. Inadequate drainage may result in the reformation of an abscess, which may require repeat incision and drainage. If not promptly diagnosed and treated, perianal abscesses may lead to several other sequelae, including fistula in ano, perianal sepsis, or necrotizing soft tissue infection of the anus and surrounding buttock. If a fistula in ano is detected, patients will need operative drainage, fistulotomy, or seton placement, which may have a risk of incontinence. Necrotizing soft tissue infection treatment goals are debridement of all non-viable tissue and may require colostomy for diversion of stool during healing. If not adequately treated, necrotizing soft tissue infection may have mortality as high as 50%.

Enhancing Healthcare Team Outcomes

Dealing with Perianal Complications in Crohn's Disease: A Need for an Interprofessional Approach

Lack of Medical Evidence

Perianal abscess in patients with Crohn disease causes significant morbidity. Even though there are several treatments for perianal abscess, very few are based on evidence.[1] Some treatments include drainage of the abscess, assessment of Crohn's disease status, determining sinus tracts, medical treatment, and surgery. With the availability of new biological therapies, the outcomes are even more conflicting. Once the abscess has been drained, attempts may be made to eradicate the fistula and control Crohn disease. The definitive treatment for perianal complications of Crohn disease is very challenging and rarely leads to complete healing. No matter what treatment is selected, one must weigh the risk of ana sphincter injury, which can be devastating. Given these facts, expert opinion suggests that an interprofessional approach to the management of perianal disease in these patients is crucial to improving outcomes.[20] Because Crohn disease is a systemic disorder, the health care team should consist of the following:

• Colorectal surgeon
• Dietitian to determine the need for nutrition
• Gastroenterologist to monitor for Crohn's disease
• Nurses to educate the patient on perianal complications
• Pharmacists to follow the prescribed drugs and ensure that the patient is not developing adverse drug reactions

Outcomes

The outcomes of perianal abscess treatment depend on the timing of the surgery. Patients with early diagnosis and treatment tend to have good outcomes, but those who have a delay in treatment usually have prolonged hospital course, need for repeated surgical treatments at higher risk of recurrence. The key to improving outcomes is to follow the patient and monitor for any perianal symptoms closely.[21] [Level V]