Anorectal Abscesses

Anorectal abscess
The right clinical information, right where it's needed
Last updated: Nov 13, 2017

Table of Contents
Summary 3
Basics 4
Definition 4
Epidemiology 4
Aetiology 4
Pathophysiology 4
Classification 4
Prevention 6
Primary prevention 6
Diagnosis 7
Case history 7
Step-by-step diagnostic approach 7
Risk factors 9
History & examination factors 10
Diagnostic tests 11
Differential diagnosis 13
Treatment 15
Step-by-step treatment approach 15
Treatment details overview 17
Treatment options 18
Follow up 22
Recommendations 22
Complications 22
Prognosis 22
Guidelines 24
Diagnostic guidelines 24
Treatment guidelines 24
Evidence scores 25
References 26
Images 29
Disclaimer 30
Summary
◊ Commonly presents with perianal pain with leukocytosis.
◊ Usually treated by incision and drainage.
◊ Adjunctive antibiotics are unnecessary for uncomplicated cases. Antibiotics are indicated for patients
with diabetes, immuno-compromise, chronic debilitation, older age, history of cardiac valvular
disease, or associated extensive cellulitis.
Anorectal abscess Basics
Definition
An anorectal abscess is an infection of the soft tissues around the anus.[1] Severe perianal pain and
swelling are the most common presenting complaints. Other symptoms include fever, chills, or urinary
BASICS
retention.[2] Rarely, patients may present with life-threatening sepsis from an associated necrotising soft-
tissue infection.[3] The diagnosis of an anorectal abscess can usually be made by physical examination, but
occasionally atypical presentations require imaging studies such as CT or MRI.[4] [5]
Epidemiology
Anorectal abscesses are a very common problem, affecting an estimated 0.18% of the general
population.[11] For patients with Crohn's disease, an anorectal abscess will develop in approximately one
third of patients. Anorectal abscesses are between 2 and 3 times more common in men than women, with
most abscesses occurring in patients between 20 to 40 years of age. The highest occurrence is during spring
and summer.[12] [13]
Aetiology
The majority of anorectal abscesses result from infections of the anal glands (cryptoglandular infections).
The anal canal has 6 to 14 glands that lie in the plane between the internal and external anal sphincters.
Ducts from these glands pass through the internal sphincters and drain into the anal crypts at the dentate
line. These glands may become infected when a crypt is occluded by impaction of food matter, by oedema
from trauma secondary to a hard stool or foreign body, or as a result of an adjacent inflammatory process
such as Crohn's disease.
Pathophysiology
The anal canal has 6 to 14 glands that lie in the plane between the internal and external anal sphincters.
Ducts from these glands pass through the internal sphincters and drain into the anal crypts at the dentate
line. If the crypt does not spontaneously drain into the anal canal, an infection of the inter-sphincteric space
may occur. This infection may spread along the inter-sphincteric space and result in an inter-sphincteric,
perianal, or supra-levator abscess. The infection may also pass through the external anal sphincter and result
in a perirectal abscess.[2] [6]
Anorectal abscesses are associated with anal fistulas in 37% of patients.[14] [15] If these fistulas are
not recognised and treated, perirectal abscesses may recur. Perirectal abscesses are also a common
manifestation of Crohn's disease and this diagnosis must be considered in patients with recurrent anorectal
abscesses.[1]
Classification
Clinical anatomical classification[6]
Anorectal abscesses are usually classified clinically, based on the anatomy of the abscess.
• Inter-sphincteric abscesses are located in the space between the internal and external anal sphincter.
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 13, 2017.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Anorectal abscess Basics
• Perianal abscesses occur in the superficial soft tissues overlying the inter-sphincteric space.
• Perirectal abscesses are found in the ischio-rectal or post-anal spaces.
[Fig-1]
• Supra-levator abscesses occur above the anorectal ring in the supra-levator space.
BASICS
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Nov 13, 2017.
5
Anorectal abscess Prevention
Primary prevention
A diet that contains 25 to 30 g/day of fibre and 60 to 80 ounces of fluid/day has not been shown to prevent
anorectal abscesses but is recommended for the prevention of hard stools, which are a risk factor for
anorectal abscesses.[12]
PREVENTION
Anorectal abscess Diagnosis
Case history
Case history #1
A 32-year-old man presents to the emergency department complaining of perirectal pain and swelling.
The symptoms began 24 hours earlier and have become progressively worse. The patient denies any
rectal bleeding and describes the pain as very severe and localised to the area of the swelling. He relates
a subjective history of fever but denies any change in bowel habits. He also denies any history of recent
or chronic medical problems.
Other presentations
An anorectal abscess can be a manifestation of Crohn's disease.[1] While severe perianal pain and
swelling are the most common presenting symptoms, 1 or both symptoms may be absent. Occasionally,
patients with anorectal abscesses will present with urinary retention. This is more common in men with
a previous history of urinary problems.[2] [7] Inter-sphincteric abscesses are very difficult to diagnose as
they produce little swelling and few perianal signs of infection. In these cases anal pain is the predominant
symptom, is usually described as being up inside the anal area, and is so severe that it precludes a digital
rectal examination.[8] Supra-levator abscesses may present with abdominal or deep pelvic pain mimicking
an intra-abdominal condition without any obvious perirectal swelling.[9] Rarely, patients with an anorectal
abscess present with life-threatening sepsis from an associated necrotising soft-tissue infection. This is
most likely in patients with diabetes, the elderly, or those who are immuno-compromised or chronically
debilitated.[3] [10]
Step-by-step diagnostic approach

The diagnosis of an anorectal abscess is usually suspected from a patient's clinical history and confirmed
by physical examination. Laboratory and radiological studies are not usually needed for the diagnosis of an
DIAGNOSIS
anorectal abscess but can be useful in some special situations.
The location of an anorectal abscess affects its diagnosis and management.[6] Inter-sphincteric abscesses
are difficult to diagnose because they produce little swelling and few perianal signs of infection, but they
are associated with anal pain that is so severe that it precludes digital rectal examination. Anaesthesia is
usually required for an adequate examination and diagnosis of the condition.[16] Supra-levator abscesses
may present with symptoms that mimic an intra-abdominal condition. Rectal examination usually reveals a
tender, indurated area above the anorectal ring, but imaging with CT or MRI may be required to make the
diagnosis.[9]
History
The presence of key risk factors such as a history of Crohn's disease or anal fistula should be elicited. In
addition, anorectal abscesses are more common in men than women.[12] [13]
Patients with anorectal abscesses usually relate a history of localised anal or perianal pain.[2] Pain
usually begins 1 to 2 days before presentation and becomes progressively more severe. Patients
frequently complain of swelling and warmth of the perianal tissues. The patient may occasionally relate
the onset to some precipitating event such as a difficult bowel movement, though pain associated only
7
with defecation is likely to be due to a fissure. The pain may be exacerbated by movement, coughing,
sneezing, or bowel movements. Patients may often try taking warm baths as pain relief, but these fail
to improve their pain or make it worse. Most patients will not report rectal bleeding unless their abscess
has spontaneously drained (usually associated with some decrease in the pain). Fever is common and is
usually <38.6ºC (101.5ºF).
Patients with rare supra-levator abscesses may describe pain in the lower abdomen or pelvis, mimicking
an intra-abdominal condition.[9] Occasionally patients with anorectal abscesses may complain of being
unable to urinate, particularly men with a previous history of difficulties with urination.[2] [7] Symptoms of
inflammation, pain, and swelling are frequently absent or diminished in patients with:[2]
• Diabetes
• Immuno-compromise
• Debilitation
• Older age
• Associated necrotising soft-tissue infection.
Physical examination
An adequate anorectal examination can usually be performed in the office or emergency department,
though on occasion this may be impossible because of pain. Inter-sphincteric and supra-levator
abscesses in particular require anaesthesia for full examination.
The most common finding on physical examination is a tender, indurated area immediately adjacent to
the anus, within the anal canal, or above the anorectal ring.[2] The further the indurated area is located
from the anal verge, the less likely it is to be an anorectal abscess. Anal fistulae associated with anorectal
abscesses may have a hard, cord-like structure leading toward the anus and palpable in the soft tissues.
Infected epidermal inclusion cysts are much more likely when the indurated area is more than 3 cm from
the anal verge while pilonidal disease is more common when the induration is located in the inter-gluteal
area.
DIAGNOSIS
Occasionally, the infection can spread to involve both ischio-rectal fossae and the post-anal space
(horseshoe abscess), though anorectal abscesses are almost always solitary. The induration in
horseshoe abscesses may be more prominent in the ischio-rectal fossae and appear to be bilateral
abscesses.[17] If multiple abscesses are present, the diagnosis is much more likely to be multiple infected
epidermoid inclusion cysts or perianal hidradenitis suppurativa.
Induration may be absent or diminished in patients with diabetes, or in those who are immuno-
compromised, debilitated, or elderly. Detection of low-grade fever and mild tachycardia should also form
part of the physical examination as these are common symptoms of anorectal abscess.
Laboratory studies
Laboratory studies are rarely helpful in the diagnosis and management of anorectal abscesses and need
not be a routine component of the evaluation and management of these patients.[2]
Basic tests include the following.
• WBC count: will frequently reveal a leukocytosis with an increased proportion of neutrophils.
Anorectal abscesses do not cause anaemia or other haematological abnormalities.
• Blood glucose: may show hyperglycaemia, which may or may not be associated with diabetes.
For patients with a necrotising soft-tissue infection related to their anorectal abscess, serum electrolyte
determination may reveal an elevated urea and creatinine, decreased bicarbonate, and an increased base
deficit (metabolic acidosis).
Abnormal blood chemistry results should generally be evaluated further only after the acute abscess
has been treated, while addressing any urgent treatment considerations acutely (e.g., volume depletion,
hyperglycaemia).
In the past, some experts recommended culture of the contents of an anorectal abscess, feeling that
the bacteriology of the abscess could be predictive of the presence of an associated anal fistula.[18]
[19] Currently, culture of the contents of an anorectal abscess is usually reserved for patients with
recurrent abscesses without a fistula identified, or for those with risk factors for one of the rare causes
of anorectal abscess such as HIV or immunosuppression, or patients from a developing region. Specific
microbiological and culture techniques may be needed to identify these unusual pathogens.[20] [21]
Radiological studies
Radiological studies are rarely helpful in the diagnosis and management of anorectal abscesses.
Occasionally, for patients with complex or atypical presentations, or those with supra-levator or horseshoe
abscesses, anal ultrasonography has been used for evaluation. However, the severe pain associated with
the anorectal abscess frequently limits the use of this modality. Other imaging modalities such as CT or
MRI may be more helpful in the evaluation of these patients.[4] [5] [22]
[Fig-1]
Risk factors
Strong
anal fistula
DIAGNOSIS
• Multiple recurrent anorectal abscesses are a common clinical manifestation of anal fistulae.
• These recurrent abscesses occur when fistulae become occluded from impaction of food matter in the
fistula tract or from healing of the skin over the external opening of the fistula.
• An anal fistula will occur in 37% of patients with an anorectal abscess.[14] [15] Fistulae result from the
drainage, either surgical or spontaneous, of the anorectal abscess.
Crohn's disease
• Anorectal abscesses will develop in approximately one third of patients with Crohn's disease.[1]
• The majority of anorectal abscesses result from infections of the anal glands (cryptoglandular
infections). The ducts from these anal glands pass through the internal sphincters, draining into the
anal crypts at the dentate line. These anal glands may become infected when a crypt is occluded as a
result of an adjacent inflammatory process such as Crohn's disease.
male gender
• Anorectal abscesses are between 2 and 3 times more common in men than women.[12] [13]
Weak
9
hard stools
• Hard stools are a risk factor for anorectal abscesses, though a diet that contains 25 to 30 g/day of fibre
and 60 to 80 ounces/day of fluid has not been shown to prevent anorectal abscesses.[12]
age 20 to 40 years
• Most anorectal abscesses occur in patients between 20 to 40 years of age.[12]
History & examination factors

Key diagnostic factors
anal fistula (common)
• Considered a key risk factor. Multiple recurrent anorectal abscesses are a common clinical
manifestation of anal fistulae. Anal fistulae may also be a complication of anorectal abscesses.
hx of Crohn's disease (common)

• Considered a key risk factor. Anorectal abscesses will develop in approximately one third of patients
with Crohn's disease.[1]
male gender (common)

• Considered a key risk factor. Anorectal abscesses are more common in men than women.[12] [13]
perianal pain (common)

• Extremely common symptom of an anorectal abscess.[2]
• Anal canal pain occurs more commonly with inter-sphincteric abscesses and pelvic pain is more
commonly due to supra-levator abscesses.
• There are very few conditions that cause anorectal pain. If the pain occurs only during and
immediately after bowel movements and improves with time, the diagnosis is more likely to be an anal
fissure rather than an anorectal abscess.
DIAGNOSIS
• Constant pain usually occurs only with thrombosed external haemorrhoids that can be diagnosed by
simple inspection of the anus or an anorectal abscess.
• Pain may be less severe in those with a compromised immune system.
perianal or rectal induration (common)

• The vast majority of patients with anorectal abscesses will have induration in the perianal tissues, in
the anal canal, or above the anorectal ring.
• This sign may be absent in those with a compromised immune system.
Other diagnostic factors

perianal swelling (common)
• Swelling and tenderness of the perianal tissues is a frequent complaint.
• Swelling may be absent in patients with inter-sphincteric or supra-levator abscesses, or those with a
compromised immune system.
low-grade fever (common)

• Most patients with an anorectal abscess have a fever, though this is usually <38.6ºC (101.5ºF).
• Fever is usually absent in those with a compromised immune system.
tachycardia (common)
• Mild tachycardia is frequently observed.
• The aetiology can be multi-factorial, including slight volume depletion from inadequate oral intake of
fluids, possibly related to fever and pain.
change in bowel habits (uncommon)

• There is seldom any change in bowel habits in patients with anorectal abscesses. A history of chronic
diarrhoea may suggest Crohn's disease, a risk factor for anorectal abscess.
rectal bleeding (uncommon)

• Usually absent unless the abscess has spontaneously drained.
• The presence of rectal bleeding is more indicative of an anal fissure.
inability to urinate (uncommon)

• Occasionally patients may complain of being unable to urinate, particularly men with a history of
difficulties with urination.[2] [7]
Diagnostic tests
1st test to order
Test Result
clinical examination often a clinical diagnosis,
although occasionally
• The diagnosis of an anorectal abscess is usually suspected from a
examination under
patient's clinical history and confirmed by physical examination.
anaesthetic is required
• An adequate anorectal examination can usually be performed in
the office or emergency department, though on occasion this may
DIAGNOSIS
be impossible because of pain. Inter-sphincteric and supra-levator
abscesses in particular require anaesthesia for full examination.
examination under anaesthetic detection of presence of
abscess
• Performed when an adequate examination cannot be performed
without anaesthesia.
• On occasion, examination without anaesthetic may be impossible
because of pain. Inter-sphincteric and supra-levator abscesses in
particular may require anaesthesia for full examination.
Other tests to consider
Test Result
WBC count may be elevated with
increased proportion of
• This may be useful in the evaluation of a patient with a suspected
granulocytes (left shift)
anorectal abscess and helps to confirm this diagnosis.
• While an elevated WBC count is very sensitive, it is not specific for an
anorectal abscess and the absence of leukocytosis does not exclude
the diagnosis.
11
Test Result
serum glucose normal or hyperglycaemia
• Useful for the management of diabetic patients with a suspected
anorectal abscess, though it may be difficult to treat the
hyperglycaemia prior to drainage of the abscess.
serum electrolytes usually normal; may
show elevated urea and
• An elevated urea and creatinine, decreased bicarbonate, and an
creatinine, decreased
increased base deficit (metabolic acidosis) are common findings in
bicarbonate
patients with necrotising soft-tissue infections and life-threatening
sepsis associated with their anorectal abscess.
• Abnormal blood chemistry results should generally be evaluated
further only after the acute abscess has been treated, while
addressing any urgent treatment considerations acutely (e.g., volume
depletion, hyperglycaemia).
anal ultrasonography visualisation of anorectal
• Anal ultrasonography is an inexpensive means to diagnose anorectal abscesses
abscesses, though it is not normally needed for diagnosis of
uncomplicated cases.
• Excessive discomfort with this modality also limits its use in the
diagnosis of inter-sphincteric and supra-levator abscesses.
CT pelvis visualisation of anorectal
abscesses
• Most anorectal abscesses are easily visualised with CT.
[Fig-1]
• While CT imaging is very sensitive and specific for anorectal
abscesses, with the possible exception of supra-levator abscesses, it
is seldom needed to make the diagnosis or determine the appropriate
treatment.[4]
• CT may be a very useful adjunct to clinical assessment in patients
with severe perirectal inflammation who are difficult to examine
without anaesthesia.[5]
MRI pelvis visualisation of anorectal
DIAGNOSIS
abscesses
• Most anorectal abscesses are easily visualised with MRI.
• While MRI imaging is very sensitive and specific for anorectal
abscesses, with the possible exception of supra-levator abscesses, it
is seldom needed to make the diagnosis or determine the appropriate
treatment.[5]
microscopic examination and/or culture of the purulent fluid may be positive for
infective organism;
• Very rarely needed or helpful except in some developing regions.
rarely positive for TB or
• Currently, culture of the contents of an anorectal abscess is
actinomycosis
usually reserved for patients with recurrent abscesses without a
fistula identified, or for those with risk factors for one of the rare
causes of anorectal abscess such as HIV or immunosuppression,
or patients from a developing region. Specific microbiological
and culture techniques may be needed to identify these unusual
pathogens.[20] [21] The contents of the abscess cavity should
be stained for acid-fast bacilli and examined with a microscope
to exclude TB. If actinomycosis is suspected, the fluid should be
examined microscopically for sulfur granules.
Differential diagnosis
Condition Differentiating signs / Differentiating tests

symptoms
Anal fissure • Pain occurs primarily during • Diagnosis is usually clinical.
bowel movements and may However, MRI or CT pelvis
improve in the next few may be used in difficult-
hours. Anal fissures are to-examine cases to
frequently associated with exclude anal fissure (both
rectal bleeding. investigations are very
• Physical examination can sensitive and specific for
distinguish between the anorectal abscesses).
2 conditions although
anaesthesia will occasionally
be needed for an adequate
examination. On physical
examination, fissures are
located in the anterior or
posterior midline, are without
induration, and are tender to
palpation. Secondary finding
of an anal fissure may be
present (sentinel pile).
Thrombosed haemorrhoid • Usually presents with the • Diagnosis is clinical.

sudden onset of perianal
pain and swelling.
• On physical examination,
thrombosed haemorrhoids
are swollen, with minimal
induration or signs of
inflammation, and are
frequently bluish in colour.
DIAGNOSIS
Pilonidal abscess • Very difficult to distinguish • MRI or CT pelvis may be
clinically, but physical used in difficult-to-examine
examination may do so. cases to exclude pilonidal
While anorectal abscesses abscess (both investigations
are usually immediately are very sensitive and
adjacent to the anus, specific for anorectal
pilonidal abscesses are abscesses).
characteristically located in
the inter-gluteal region and
frequently have a visible
sinus tract in the midline.
Infected epidermoid • Difficult to distinguish • MRI or CT pelvis may be

inclusion cyst clinically, but physical used in difficult-to-examine
examination can do so in cases to exclude infected
some cases. While anorectal epidermoid inclusion cyst
abscesses are usually (both investigations are very
immediately adjacent to the sensitive and specific for
anus, infected epidermoid anorectal abscesses).
inclusion cysts are more
commonly >3 cm from the
anal verge.
13
Condition Differentiating signs / Differentiating tests

symptoms
Perianal hidradenitis • The presenting signs and • Diagnosis is usually clinical.
suppurativa symptoms are the same
as those for anorectal
abscesses, but physical
examination can often
distinguish between
the conditions. Perianal
hidradenitis suppurativa
is usually associated with
hidradenitis in other areas,
most commonly the axilla
and inguinal areas. While
anorectal abscesses are
usually single, abscesses
associated with hidradenitis
are more commonly multiple
and usually associated
with purulent drainage from
multiple sinus tracts.
STDs • History of anal-receptive • Rectal swab for microscopy,

sex with or without Gram stain, and culture
immunosuppression (e.g., usually reveals the causative
HIV), rectal discharge, organism (e.g., Neisseria
severe anal pain, malaise gonorrhoeae , Chlamydia
may be present. trachomatis , Herpes
• Physical examination may simplex , Treponema
reveal systemic fever, pallidum ).
lymphadenopathy, anal • In addition, stool microscopy
discharge. In addition, rectal and culture, serological
examination, usually under testing, and tissue biopsy
anaesthesia, will reveal may help confirm diagnosis.
rectal mucosal changes
DIAGNOSIS
consistent with proctitis.
Anorectal abscess Treatment
Step-by-step treatment approach

The goal of treatment of anorectal abscesses is to achieve adequate drainage of the abscess without
damaging the anal sphincters. Antibiotics are not an alternative to surgical drainage of these abscesses
and should be used as an adjunctive treatment for patients with diabetes, immuno-compromise, chronic
debilitation, older age, history of cardiac valvular disease, or significant associated cellulitis.[2] In these
circumstances, a broad-spectrum antibiotic with anaerobic and gram-negative coverage would be
appropriate. Drainage of the abscess should be accomplished without undue delay because of the potential
for the abscess to spread into a necrotising, soft-tissue infection leading to life-threatening sepsis.[10] [23]
The development of a necrotising, soft-tissue infection is more common in the elderly, patients with diabetes,
and immunosuppressed individuals (e.g., patients with HIV, alcoholism, or malignancy; those receiving
chemotherapy; those with history of solid organ transplant), and has been reported to have a mortality
between 25% and 35%.[24]
External drainage of perianal and perirectal abscess is appropriate, while inter-sphincteric and supra-levator
abscesses should be drained internally into the anal canal and rectum, respectively, to avoid the creation of
extra-sphincteric or supra-sphincteric fistulas. For patients with anorectal abscesses associated with Crohn's
disease, treatment of the underlying condition should be considered after the acute anorectal sepsis has
been treated.[1] [25] The management of an anal fistula is controversial.[15] [26] [27] [28] [29]
Surgical management
Perianal abscesses can frequently be drained in the office or emergency department using local
anaesthesia and drained externally using an incision that is oriented in a radial fashion relative to the
anus. This incision has the potential to damage the anal sphincters if the incision is extended too far
medially, but in those patients who have an associated anal fistula, it will make subsequent fistula
management simpler. Perirectal abscesses should be drained in the operating room where optimal
anaesthesia can be achieved.
An alternative for drainage of the abscess is a curvilinear incision that is parallel to the anus. This incision
has a decreased risk to the anal sphincters, but can make subsequent management more challenging for
those patients with an associated anal fistula. Whichever incision is used, either an ellipse of skin can be
removed, or a second, smaller incision can be made perpendicular to the primary incision at its midpoint
(cruciate incision) to prevent reapproximation of the skin edges. A small drainage catheter can be used to
facilitate drainage of deeper infections.
If examination at the time of surgical drainage reveals an associated anal fistula, consideration can be
given to managing the fistula at the same time.[26] [28] [29] A Cochrane review has suggested that
fistula surgery should be carried out at the time of abscess drainage, as this reduces the persistence
and recurrence of the abscess/fistula and the need for further surgery, and that the intervention should
be recommended in carefully selected patients. 1[A]Evidence Anal fistulae that are superficial, involving
no more than 25% of the sphincter mechanism, can be managed by fistulotomy. An alternative would
be the placement of a loose, plastic seton to act as a drain.[15] [27] The seton will reduce the risk of
recurrent anorectal abscess and will allow for sphincter-preserving management of the fistula after the
TREATMENT
acute infection has resolved and the fistula tract has matured. If the anal fistula is found to involve more
than 25% of the sphincter mechanism, fistulotomy is not an option but consideration can still be given to
placement of a seton to prevent recurrent anorectal abscess.[23]
15
If the abscess is being drained outside the operating room or under local anaesthesia, it may not be
possible to perform an adequate anal examination or place a seton. In this circumstance, there is a risk
of recurrent anorectal abscess. Inter-sphincteric and supra-levator abscesses frequently require general
anaesthesia to allow for an adequate anal examination to make a diagnosis and drain the abscess. These
abscesses should be drained internally into the anal canal and rectum, respectively.[9] [16] Anal fistulas
only rarely occur after drainage of these abscesses so there is no need to consider fistula management at
the time of abscess drainage.
Postoperative wound care

Postoperatively, patients should begin comfortably warm water baths 2 or 3 times daily to clean the wound
until the complete healing has occurred. Baths should also be used for cleansing after bowel movements.
Absorbent dressings can be used to prevent staining of the underclothes if drainage continues.
Adjunctive antibiotic therapy

Usually reserved for patients with diabetes, immuno-compromise, chronic debilitation, older age,
history of cardiac valvular disease, or significant associated cellulitis.[2] Broad-spectrum antibiotics with
anaerobic and gram-negative coverage should be started preoperatively and be discontinued within 24
hours of surgery or after cellulitis has resolved. There is no standardised antibiotic regime in the literature.
In general, some combination of an IV broad-spectrum penicillin (e.g., ampicillin/sulbactam) or a second-
or third-generation cephalosporin (e.g., cefoxitin or cefotetan) is combined with either clindamycin,
ciprofloxacin, or metronidazole.
There is no clinical evidence to support triple antibiotic coverage. While some authors also recommend
adding an aminoglycoside (gentamicin or tobramycin) to the regimen, potential complications should be
considered. Aminoglycosides are known to cause nephro- and ototoxicity. If used for more than 24 hours,
serum levels need to be monitored.
For patients who present with a necrotising soft-tissue infection, broad-spectrum antibiotics as described
above are mandatory. In addition, a more aggressive surgical approach is warranted with complete
debridement of infected soft tissues. Multiple trips to the operating room are frequently needed before the
necrotising process is brought under control. Given the lethality of necrotising soft-tissue infections, care
in an ICU is necessary. [24]
Treatment failure
Adequate drainage of the abscess should result in a prompt improvement in the symptoms. If not, re-
examination under anaesthesia is indicated to ensure complete drainage of the abscess. Inadequate
drainage of the abscess occurs most commonly in patients with horseshoe abscesses when the post-anal
or ischio-rectal component of the abscess is more prominent and is drained, but the other components of
this abscess are not recognised and treated.[31] [32]
Recurrence of the anorectal abscess will occur in about 11% of patients, usually from an unrecognised
anal fistula. For patients who develop a recurrent anorectal abscess or whose wound from the initial
drainage fails to heal, examination by a general or colorectal surgeon is indicated to exclude an anal
TREATMENT
fistula as the cause of these problems. For patients with recurrent anorectal abscess and risk factors such
as HIV or immunosuppression, or patients from a developing region, consideration may also be given to
some of the rare causes of anorectal abscess such as TB or actinomycosis. Specific microbiological and
culture techniques may be needed to identify these conditions.[20] [21]
Treatment details overview

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Acute ( summary )
Patient group Tx line Treatment
all patients 1st surgical drainage of abscess
plus postoperative care
adjunct fistulotomy
elderly, immuno- plus broad-spectrum antibiotics with anaerobic

compromised, cardiac and gram-negative coverage
valvular disease, diabetes,
or significant associated
cellulitis
elderly, immuno- adjunct aminoglycosides

compromised, cardiac
cellulitis
unresponsive to initial plus re-examination under anaesthesia/

treatment exclusion of rare microbiological cause
TREATMENT
17
Treatment options
Acute
all patients 1st surgical drainage of abscess

» Drainage of the abscess should be
accomplished without undue delay because
of the potential for the abscess to spread into
a necrotising, soft-tissue infection with life-
threatening sepsis.[3]
» Perianal abscesses can frequently be drained

in the office or emergency department using
local anaesthesia and drained externally.
Perirectal abscesses should be drained in the
operating room where optimal anaesthesia can
be achieved.
» Inter-sphincteric and supra-levator abscesses

frequently require general anaesthesia for an
adequate anal examination for diagnosis and to
drain the abscess. These abscesses should be
drained internally into the anal canal and rectum,
respectively.[9] [16]
plus postoperative care

» Patients should begin baths with comfortably
warm water 2 or 3 times daily postoperatively to
clean the wound until healed. Warm water baths
should also be used for cleansing after bowel
movements.
» Absorbent dressings can be used to prevent

staining of underclothes if there is drainage.
» A diet containing 25 g to 30 g of dietary fibre/

day and 60 to 80 ounces/day of fluid should be
considered to prevent hard stools.
adjunct fistulotomy
» If examination at the time of surgical drainage
reveals an associated anal fistula (usually with
perianal or perirectal abscesses; rarely with
intersphincteric or supralevator abscesses),
consideration can be given to managing
the fistula at the same time.[26] [28] [29]
TREATMENT
1[A]Evidence Anal fistulae that are superficial,

involving no more than 25% of the sphincter
mechanism can be managed by fistulotomy. An
alternative would be the placement of a loose,
plastic seton to act as a drain.[15] [27] The
seton reduces the risk of recurrent anorectal
Acute
abscess and allows for sphincter-preserving
management of the fistula after the acute
infection has resolved and the fistula tract has
matured. If the anal fistula involves more than
25% of the sphincter mechanism, fistulotomy
is not an option but placement of a seton to
prevent recurrent anorectal abscess can still be
considered.[23]
» If the abscess is being drained outside the

operating room or under local anaesthesia, it
may not be possible to perform an adequate
anal examination or place a seton. In this
circumstance, there is a risk of recurrent
anorectal abscess.
elderly, immuno- plus broad-spectrum antibiotics with anaerobic

compromised, cardiac and gram-negative coverage
» Broad-spectrum antibiotics with anaerobic
and gram-negative coverage should be started
cellulitis
preoperatively and be discontinued within 24
hours of surgery or after cellulitis has resolved.
» There is no standardised antibiotic regime in

the literature.
» In general, some combination of an IV

broad-spectrum penicillin (e.g., ampicillin/
sulbactam) or a second- or third-generation
cephalosporin (e.g., cefoxitin or cefotetan) is
combined with either clindamycin, ciprofloxacin,
or metronidazole.
» For patients who present with a necrotising

soft-tissue infection, broad-spectrum antibiotics
as described above are mandatory. In addition, a
more aggressive surgical approach is warranted
with complete debridement of infected soft
tissues. Multiple trips to the operating room are
frequently needed before the necrotising process
is brought under control. Given the lethality of
necrotising soft-tissue infections, care in an ICU
is necessary. [24]
Primary options
» ampicillin/sulbactam: 1 g orally/
intravenously every 6 hours
Dose refers to ampicillin component.
TREATMENT
-or-
» cefoxitin: 1 g intravenously every 8 hours
-or-
» cefotetan: 1-2 g intravenously every 12
hours
19
Acute
--AND--
» metronidazole: 500 mg orally/intravenously
every 6 hours
-or-
» ciprofloxacin: 200-400 mg intravenously
every 12 hours; 500 mg orally every 12 hours
-or-
» clindamycin: 600 mg orally/intravenously
every 8 hours
elderly, immuno- adjunct aminoglycosides
compromised, cardiac
» There is no clinical evidence to support
triple antibiotic coverage. While some authors
also recommend adding an aminoglycoside
cellulitis
(gentamicin or tobramycin) to the regimen,
potential complications should be considered.
» Treatment is for 24 hours or until the cellulitis

has resolved.
» Aminoglycosides are known to cause nephro-

and ototoxicity. If used for more than 24 hours,
serum levels need to be monitored.
Primary options
» gentamicin: 80 mg intravenously every

8 hours for 24 hours or until cellulitis has
resolved
OR
Primary options
» tobramycin: 80 mg intravenously every

8 hours for 24 hours or until cellulitis has
resolved
unresponsive to initial plus re-examination under anaesthesia/
treatment exclusion of rare microbiological cause
» Adequate drainage of the abscess should
result in a prompt improvement of symptoms.
If not, re-examination under anaesthesia is
recommended to ensure complete drainage of
the abscess.
» Inadequate drainage of the abscess occurs

most commonly in patients with horseshoe
abscesses when the post-anal or ischio-
rectal component of the abscess is more
TREATMENT
prominent and is drained, but the other abscess

components are not recognised and treated.[17]
» For patients who develop a recurrent anorectal

abscess or whose wound from the initial
drainage fails to heal, examination by a general
Acute
or colorectal surgeon is indicated to exclude an
anal fistula as the cause of these problems.[14]
[15]
» For patients with recurrent anorectal

abscess and risk factors such as HIV,
immunosuppression, or patients from a
developing region, consideration may also be
given to some of the rare causes of anorectal
abscess, such as TB or actinomycosis. Specific
microbiological and culture techniques may be
needed to identify these conditions.[21] [20]
TREATMENT
21
Anorectal abscess Follow up
Recommendations
Monitoring
FOLLOW UP
Routine postoperative follow-up with perianal examination is needed every 2 to 3 weeks until the surgical
wound has healed. Recurrence of the abscess or persistence of the wound after 6 weeks is strongly
suggestive of an associated anal fistula and in these cases further evaluation is warranted.
Patient instructions
Postoperatively, patients should be instructed to begin baths with comfortably warm water 2 or 3 times
daily to clean the perianal area until the surgical wound has healed. Warm water baths should also be
used for cleansing after bowel movements. Absorbent dressings can be used to prevent staining of the
underclothes. A diet that contains 25 to 30 g of dietary fibre/day and 60 to 80 ounces/day of fluid should
be considered to prevent hard stools.
Complications
Complications Timeframe Likelihood

necrotising soft-tissue infection short term low
Necrotising soft-tissue infections of the perineum (Fournier's gangrene) with life-threatening sepsis
may be present or develop in patients with anorectal abscesses when there is a delay in diagnosis or
management.
This is more likely to occur in patients with diabetes, immuno-compromise, chronic debilitation, or older
age.[3] [10]
anal fistula variable high
An associated anal fistula will be present or develop in about 37% of patients with an anorectal
abscess.[14] [15]
If examination at the time of surgical drainage reveals an associated anal fistula, while controversial,
consideration can be given to managing the fistula at the same time.[26] [28] [29] 1[A]Evidence If the anal
fistula is superficial and involves no more than 25% of the sphincter mechanism, some surgeons feel that
the anal fistula can be managed by fistulotomy.
Prognosis
Adequate drainage of the abscess should result in a prompt improvement in the symptoms.[17] Recurrence
of the anorectal abscess occurs in <2% of patients unless there is an associated anal fistula.[14] [15]
Recurrence
Anorectal abscesses are associated with an anal fistula in about 37% of patients. A common clinical
manifestation of these anal fistulas is recurrent anorectal abscesses.[14] [15] These recurrent abscesses
Anorectal abscess Follow up
occur when the fistula becomes occluded from impaction of food matter in the fistula tract or from healing of
the skin over the external opening of the fistula.
FOLLOW UP
23
Anorectal abscess Guidelines
Diagnostic guidelines
Europe
German S3 guideline: anal abscess [in German]

Published by: Association of the Scientific Medical Societies in Last published: 2016
Germany
North America
Practice parameters for the management of perianal abscess and fistula-in-

ano
Published by: American Society of Colon and Rectal Surgeons Last published: 2011
Summary: Evidence-based guidelines. Anorectal abscess is usually diagnosed based on clinical findings
alone; however, adjunctive radiological studies such as CT, MRI, and ultrasound can provide valuable
GUIDELINES
information in complex tracts or recurrent disease.
Treatment guidelines
Europe
German S3 guideline: anal abscess [in German]

Published by: Association of the Scientific Medical Societies in Last published: 2016
Germany
North America
Practice parameters for the management of perianal abscess and fistula-in-

ano
Published by: American Society of Colon and Rectal Surgeons Last published: 2011
Summary: Evidence-based guidelines that recommend incision and drainage as a first-line treatment
option. Antibiotics have a limited role in treatment of uncomplicated disease; however, they may be
considered in patients who are immunosuppressed, have a concomitant illness, or have significant
cellulitis.
Anorectal abscess Evidence scores
Evidence scores
1. Reduction in recurrence, persistent abscess/fistula, or repeat surgery: there is good-quality evidence
that patients with perianal abscess treated with incision and drainage with fistula treatment had a
significant reduction in recurrence, persistent abscess/fistula, or repeat surgery compared with those
having incision and drainage of perianal abscess alone. Incontinence at 1 year following drainage with
fistula surgery was not found to be statistically significant.[30]
Evidence level A: Systematic reviews (SRs) or randomized controlled trials (RCTs) of >200
participants.
EVIDENCE SCORES
25
Anorectal abscess References
Key articles
• Nomikos IN. Anorectal abscesses: need for accurate anatomical localization of the disease. Clin Anat.
REFERENCES
1997;10:239-244. Abstract
• Gilliland R, Wexner SD. Complicated anorectal sepsis. Surg Clin North Am. 1997;77:115-153. Abstract
References
1. Michelassi F, Melis M, Rubin M, et al. Surgical treatment of anorectal complications in Crohn's
disease. Surgery. 2000;128:597-603. Abstract
2. Marcus RH, Stine RJ, Cohen MA. Perirectal abscess. Ann Emerg Med. 1995;25:597-603. Abstract
3. Adinolfi MF, Voros DC, Moustoukas NM, et al. Severe systemic sepsis resulting from neglected
perineal infections. South Med J. 1983;76:746-749. Abstract
4. Guillaumin E, Jeffrey RB Jr, Shea WJ, et al. Perirectal inflammatory disease: CT findings. Radiology.
1986;161:153-157. Abstract
5. Rafal RB, Nichols JN, Cennerazzo WJ, et al. MRI for evaluation of perianal inflammation. Abdom
Imaging. 1995;20:248-252. Abstract
6. Nomikos IN. Anorectal abscesses: need for accurate anatomical localization of the disease. Clin Anat.
1997;10:239-244. Abstract
7. Godec CJ, Cass AS, Ruiz E. Another aspect of acute urinary retention in young patients. Ann Emerg
Med. 1982;11:471-474. Abstract
8. Ramanujam PS, Prasad ML, Abcarian H, et al. Perianal abscesses and fistulas. A study of 1023
patients. Dis Colon Rectum. 1984;27:593-597. Abstract
9. Prasad ML, Read DR, Abcarian H. Supralevator abscess: diagnosis and treatment. Dis Colon Rectum.
1981;24:456-461. Abstract
10. Salvino C, Harford FJ, Dobrin PB. Necrotizing infections of the perineum. South Med J.
1993;86:908-911. Abstract
11. Gilliland R, Wexner SD. Complicated anorectal sepsis. Surg Clin North Am. 1997;77:115-153. Abstract
12. Kovalcik PJ, Peniston RL, Cross GH. Anorectal abscess. Surg Gynecol Obstet. 1979;149:884-886.
Abstract
13. Read DR, Abcarian H. A prospective survey of 474 patients with anorectal abscess. Dis Colon
Rectum. 1979;22:566-568. Abstract
14. Hamalainen KP, Sainio AP. Incidence of fistulas after drainage of acute anorectal abscesses. Dis
Colon Rectum. 1998;41:1357-1361. Abstract
REFERENCES
15. Vasilevsky CA, Gordon PH. The incidence of recurrent abscesses or fistula-in-ano following anorectal
suppuration. Dis Colon Rectum. 1984;27:126-130. Abstract
16. Millan M, Garcia-Granero E, Esclapez P, et al. Management of intersphincteric abscesses. Colorectal

Dis. 2006;8:777-780. Abstract
17. Onaca N, Hirshberg A, Adar R. Early reoperation for perirectal abscess: a preventable complication.
Dis Colon Rectum. 2001;44:1469-1473. Abstract
18. Grace RH, Harper IA, Thompson RG. Anorectal sepsis: microbiology in relation to fistula-in-ano. Br J
Surg. 1982;69:401-403. Abstract
19. Lunniss PJ, Phillips RK. Surgical assessment of acute anorectal sepsis is a better predictor of fistula
than microbiological analysis. Br J Surg. 1994;81:368-369. Abstract
20. Magdeburg R, Grobholz R, Dornschneider G, et al. Perianal abscess caused by Actinomyces: report
of a case. Tech Coloproctol. 2008;12:347-349. Abstract
21. Samarasekera DN, Nanayakkara PR. Rectal tuberculosis: a rare cause of recurrent rectal suppuration.
Colorectal Dis. 2008;10:846-847. Abstract
22. Steele SR, Kumar R, Feingold DL, et al. Practice parameters for the management of perianal abscess
and fistula-in-ano. Dis Colon Rectum. 2011;54:1465-1474. Abstract
23. Williams JG, MacLeod CA, Rothenberger DA, et al. Seton treatment of high anal fistulae. Br J Surg.
1991;78:1159-1161. Abstract
24. Sarani B, Strong M, Pascual J, et al. Necrotizing fasciitis: current concepts and review of the literature.
J Am Coll Surg. 2009;208:279-288. Abstract
25. Sangwan YP, Schoetz DJ Jr, Murray JJ, et al. Perianal Crohn's disease. Results of local surgical
treatment. Dis Colon Rectum. 1996;39:529-535. Abstract
26. Tang CL, Chew SP, Seow-Choen F. Prospective randomized trial of drainage alone vs. drainage
and fistulotomy for acute perianal abscesses with proven internal opening. Dis Colon Rectum.
1996;39:1415-1417. Abstract
27. Schouten WR, van Vroonhoven TJ. Treatment of anorectal abscess with or without primary
fistulectomy. Results of a prospective randomized trial. Dis Colon Rectum. 1991;34:60-63. Abstract
28. Cox SW, Senagore AJ, Luchtefeld MA, et al. Outcome after incision and drainage with fistulotomy for
ischiorectal abscess. Am Surg. 1997;63:686-689. Abstract
29. Knoefel WT, Hosch SB, Hoyer B, et al. The initial approach to anorectal abscesses: fistulotomy is safe
and reduces the chance of recurrences. Dig Surg. 2000;17:274-278. Abstract
27
30. Malik A, Nelson RL, Tou S. Incision and drainage of perianal abscess with or without treatment of anal
fistula. Cochrane Database Syst Rev. 2010;(7):CD006827. Full text Abstract
REFERENCES
31. Garcia-Aguilar J, Belmonte C, Wong WD, et al. Anal fistula surgery. Factors associated with
recurrence and incontinence. Dis Colon Rectum. 1996;39:723-729. Abstract
32. Chrabot CM, Prasad ML, Abcarian H. Recurrent anorectal abscesses. Dis Colon Rectum.
1983;26:105-108. Abstract
Anorectal abscess Images
Images
IMAGES
Figure 1: CT demonstrating a perirectal abscess
From the collection of Dr C. Neal Ellis; used with permission
29
Anorectal abscess Disclaimer
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considered a substitute for that.
This information is not intended to cover all possible diagnosis methods, treatments, follow up, drugs and
any contraindications or side effects. In addition such standards and practices in medicine change as new
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DISCLAIMER
Contributors:
// Authors:
Jan Rakinic, MD, FACS, FASCRS

Professor of Surgery
Chief, Section of Colorectal Surgery, Southern Illinois University School of Medicine, Springfield, IL
DISCLOSURES: JR is an author of a reference cited in this monograph.
// Acknowledgements:
Dr Jan Rakinic would like to gratefully acknowledge Dr C. Neal Ellis, a previous contributor to this
monograph. CNE declares that he has no competing interests.
// Peer Reviewers:
Mark H. Whiteford, MD
Assistant Professor of Surgery
Colon and Rectal Surgery, Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic,
Portland, OR
DISCLOSURES: MHW declares that he has no competing interests.
Neil Hyman, MD
Chief
Division of General Surgery, Professor of Surgery, Fletcher Allen Healthcare, Burlington, VT
DISCLOSURES: NH declares that he has no competing interests.
Steven Brown, MBChB, FRCS, MD, BMedSci

Consultant Surgeon
Department of Colorectal Surgery, Sheffield Teaching Hospitals, Sheffield, UK
DISCLOSURES: SB declares that he has no competing interests.

Anorectal Abscesses

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Anorectal Abscesses

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Anorectal abscess

The right clinical information, right where it's needed

Last updated: Nov 13, 2017

◊ Commonly presents with perianal pain with leukocytosis.

◊ Usually treated by incision and drainage.

Step-by-step diagnostic approach

Basic tests include the following.

History & examination factors

hx of Crohn's disease (common)

male gender (common)

perianal pain (common)

perianal or rectal induration (common)

Other diagnostic factors

low-grade fever (common)

change in bowel habits (uncommon)

rectal bleeding (uncommon)

inability to urinate (uncommon)

Other tests to consider

Condition Differentiating signs / Differentiating tests

Thrombosed haemorrhoid • Usually presents with the • Diagnosis is clinical.

Infected epidermoid • Difficult to distinguish • MRI or CT pelvis may be

Condition Differentiating signs / Differentiating tests

STDs • History of anal-receptive • Rectal swab for microscopy,

consistent with proctitis.

Step-by-step treatment approach

Postoperative wound care

Adjunctive antibiotic therapy

Treatment details overview

all patients 1st surgical drainage of abscess

plus postoperative care

elderly, immuno- plus broad-spectrum antibiotics with anaerobic

elderly, immuno- adjunct aminoglycosides

unresponsive to initial plus re-examination under anaesthesia/

all patients 1st surgical drainage of abscess

» Perianal abscesses can frequently be drained

» Inter-sphincteric and supra-levator abscesses

plus postoperative care

» Absorbent dressings can be used to prevent

» A diet containing 25 g to 30 g of dietary fibre/

1[A]Evidence Anal fistulae that are superficial,

» If the abscess is being drained outside the

elderly, immuno- plus broad-spectrum antibiotics with anaerobic

» There is no standardised antibiotic regime in

» In general, some combination of an IV

» For patients who present with a necrotising

» Treatment is for 24 hours or until the cellulitis

» Aminoglycosides are known to cause nephro-

» gentamicin: 80 mg intravenously every

» tobramycin: 80 mg intravenously every

» Inadequate drainage of the abscess occurs

prominent and is drained, but the other abscess

» For patients who develop a recurrent anorectal

» For patients with recurrent anorectal

Complications Timeframe Likelihood

anal fistula variable high

German S3 guideline: anal abscess [in German]

Practice parameters for the management of perianal abscess and fistula-in-

information in complex tracts or recurrent disease.

German S3 guideline: anal abscess [in German]

Practice parameters for the management of perianal abscess and fistula-in-

16. Millan M, Garcia-Granero E, Esclapez P, et al. Management of intersphincteric abscesses. Colorectal

View our full Website Terms and Conditions.

Jan Rakinic, MD, FACS, FASCRS