PERIANAL ABSCESS

Dr. Azares, January 15, 2018 4.01b

Microbes that enter the anal gland vary (Enterococcus,
I. CRYPTOGLANDULAR ABSCESS
Bacteroides, E.coli, Klebsiella, Proteus, etc.). Therefore initial
A. Anatomy of Anal Spaces
infection of the anal gland can progress to abscess in one week
1. Perianal Space despite antibiotics.
2. Intersphincteric Space
3. Ischiorectal Space I-A. ANATOMY OF ANAL SPACES
4. Supralevator Space
B. Types of Anorectal Abscess As an abscess enlarges, it spreads in one of several directions
through the anal spaces.
1. Perianal Abscess
2. Ischiorectal Abscess
3. Supralevator Abscess
4. Intersphincteric Abscess
II. FOURNIER’S GANGRENE
III. FISTULA-IN-ANO
A. Classification of FIA
1. Intersphincteric Fistula
2. Transsphincteric Fistula
3. High Sphincteric Fistula
4. Extrasphincteric Fistula
B. Salmon and Goodsall’s Rule Figure 2: Anatomy of Perianorectal Spaces (Schwartz)
IV. TREATMENT
A. Anal Fistulotomy
B. Different Options to Close the Internal Opening
1. Endorectal Advancement Flap
2. Lift Procedure
3. Anal Fistula Plug
4. Seton

I. CRYPTOGLANDULAR ABSCESS
Majority of anorectal suppurative disease results from
infections of the anal glands known as cryptoglandular
infection found in the intersphincteric plane. Their ducts
traverse the internal sphincter and empty into the anal crypts
at the level of the dentate line. Figure 3: Pathways of Anorectal Infection in Perianal Spaces
Infection of an anal gland results in the formation of an abscess (Schwartz)
that enlarges and spreads along one of several planes in the
perianal and perirectal spaces I-A-1. PERIANAL SPACE
The perianal space surrounds the anus and laterally becomes
continuous with the fat of the buttocks.

I-A-2. INTERSPHINCTERIC SPACE

The intersphincteric space separates the internal and external
anal sphincters. It is continuous with the perianal space distally
and extends cephalad into the rectal wall.

I-A-3. ISCHIORECTAL SPACE

Figure 1: Cryptoglandular Infection
From Recording:
Microbes such as S. Aureus enters the pores and not the skin
Infection enters through the crypts of the dentate line
Each anal gland in the dentate gland has its own pore opening
to the crypts of the dentate line.
The ischiorectal space is located lateral and posterior to the
anus and is bounded medially by the external sphincter,
laterally by the ischium, superiorly by the levator ani and
inferiorly by the transverse septum.
It also contains the inferior rectal vessels and lymphatics
connect posteriorly above the anococcygeal ligament but
below the levator ani muscle forming the deep postnatal
space.
Two ischiorectal space

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bb I-A-4. SUPRALEVATOR SPACE These abscesses may become extremely large and may not be
visible in the perianal region
The supralevator space lie above the levator ani on either side Horseshoe abscess – an ischiorectal abscess causes diffuse
of the rectum and communicate posteriorly. swelling in the ischiorectal fossa that may involve one or both
sides
I-B. TYPES OF ANORECTAL ABSCESS

I-B-1. PERIANAL ABSCESS

 Most common type of abscess and appears as painful swelling
at the anal verge.

Figure 6: Ischiorectal Abscess

Located distal from the anal verge.

I-B-3. SUPRALEVATOR ABSCESS

Figure 4: Perianal Abscess Uncommon and may result from extension of an

intersphincteric or ischiorectal abscess upward or extension of
(From Recording:) an intraperitoneal abscess downward.
80% of anal glands do not penetrate the internal anal Can mimic intra-abdominal conditions due to its proximity to
sphincter. The internal anal sphincter is softer than the external the peritoneal cavity
anal sphincter. 15% of the time, part of the anal gland is No external manifestation because it is above the
embedded on the internal anal sphincter. When the embedded puborectalis muscle
parts get infected, they are pressurized with pus. The pus is It is located >4cm from the anal verge.
able to easily penetrate the fibers of the internal anal Bulge can be felt during DRE.
sphincter, lodging into the space between the internal and DRE may reveal an indurated, bulging mass above the
external sphincters. The space between the sphincters is very anorectal ring
loose hence the infection goes down the perianal abscess.

Figure 7: Supralevator Abscess

Figure 5: Perianal Abscess I-B-4. INTERSPHINCTERIC ABSCESS

Occur in the intersphincteric space and are notoriously difficult
Perianal space is underneath the anal verge
to diagnose because they produce little swelling and few
perianal signs of infection, often requiring an examination
I-B-2. ISCHIORECTAL ABSCESS
under anesthesia.
On worse cases, pressurized pus is lodged on the external anal Pain is typically described as being deep and “up inside” the
sphincter and enters the ischiorectal space leading to anal area and exacerbated by coughing or sneezing
ischiorectal abscess.
DRE will reveal a painful swelling laterally in the ischiorectal
fossa.

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bb I-C. DIAGNOSIS Abscess can be drained through a limited, usually

posterior, internal sphincterotomy
 GOOD HISTORY AND PHYSICAL EXAMINATION!
 DRE is contraindicated when there is tenderness. I-D-1. 3 PROBLEMS
1. Infected Anal Gland
Severe anal pain is the most common presenting complaint. 2. Tracts
A palpable mass is often detected by inspection of the perianal
3. Abscess
area or by DRE.
Occasionally, patients will present with fever, urinary
retention, or life-threatening sepsis.
Diagnosis of a perianal or ischiorectal abscess can usually be
made with physical exam alone. However, complex or atypical
presentations may require imaging studies (CT or MRI) to fully
delineate the anatomy of the abscess.

I-D. TREATMENT
 INCISION AND DRAINAGE with or without primary
fistulotomy
o Prone Jack Knife position under spinal anesthesia
o Emergency surgery for perianal abscess and ischiorectal
abscess (do not give antibiotics anymore)

Anorectal abscess should be treated by drainage as soon as

diagnosis is established.
Delayed or inadequate treatment may occasionally cause Figure 8: Incision and Drainage
extensive and life-threatening suppuration with massive tissue
necrosis and septicemia. Incision and drainage only solves problem number 3 (abscess)
Antibiotics are only indicated if there is extensive overlying Tracts are very difficult to find due to hair-like width and
cellulitis or if the patient is immunocompromised, has DM, or edematous surrounding. Finding the tract can lead to creation
has a valvular heart disease. of false tracts hence creating more problems.
Antibiotics alone are ineffective at treating perianal or In incision and drainage, 50% of the patients will heal and 50%
perirectal infection. will be converted to fistula-in- ano or further ischiorectal
abscess.
Perianal abscess:
Most can be drained under local anesthesia I-E. SUMMARY OF ANORECTAL ABSCESS
Skin incision is created, and a disk of skin in excised to
Perianal Ischiorectal Supralevator
prevent premature closure
Route of Intersphincteric External anal Intersphincteric
Sitz baths
Spread space sphincter or ischiorectal
(2018 A) abscess
Ischiorectal abscess:
upward
Simple ischiorectal absesses are drained through an
incision in the overlying skin.
Or
Horseshoe abscesses require drainage of the deep
postanal space and often require counter incisions over
Extension of
one or both ischiorectal spaces.
intraperitoneal
abscess
Supralevator abscess:
downwards
It is essential to identify the origin of the abscess prior to
Clinical Painful swelling Painful swelling No external
treatment.
Manifest at anal verge distal the anal manifestations
If abscess is secondary to an upward extension of an
ations verge (located >4cm
intersphincteric abscess, it should be drained through the
from the anal
rectum
Horseshoe verge)
If it arises from the upward extension of an ischiorectal
abscess
abscess, it should be drained through the ischiorectal
DRE Painful swelling Indurated,
fossa
laterally in the bulging mass
If it is secondary to intra-abdominal disease, the primary
ischiorectal above the
process requires treatment and the abscess drained via
fossa. anorectal ring
the most direct route (transabdominally, rectally, or
through the ischiorectal fossa)
Tx Incision and Drainage with or
Intersphincteric abscess: without primary fistulotomy

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bb II. FOURNIER’S GANGRENE

Figure 9: Fournier’s Gangrene, aka necrotizing fasciitis

 Most dreaded complication of neglected abscess in

immunocompromised patients as well as necrotizing fasciitis.
 Has a very high mortality rate of >90%
 Abscesses contains multi-organisms hence worse the infection
Emergency procedure Figure 10: Classifications of FIA.

III. FISTULA-IN-ANO (FIA) (1,a) Intersphincteric Fistula

(2,b) Transsphincteric Fistula
1. It is the end result of perforated perianal abscess, leading to
(3,c) High Transsphincteric Fistula
the production of:
(4,d) Extrasphincteric Fistula
1. an external opening
2. a tract
3. an internal opening
Bombardment with antibiotics will not resolve the fistula since
constant contamination will occur from bowel movements
2. Drainage of an anorectal abscess results in cure for about 50%
III-A-1. INTERSPHINCTERIC FISTULA
of patients while the other 50% develop persistent fistula-in- Most common anal fistula
ano. Tracks through the distal internal sphincter and
o Drained abscess closes but may eventually produce a tiny
intersphincteric space to an external opening near the anal
opening and develop a tract that goes through the
verge
infected anal gland producing fistula-in-ano.
o The course of the fistula often can be predicted by the Pathway:
anatomy of the previous abscess (2016A). o Distal internal sphincter  intersphincteric space 
o Majority of fistulas are cryptoglandular in origin external opening near the anal verge
 Fistula produces internal and external openings. Confined to the intersphincteric plane
The fistula usually originates in the infected crypt (internal Treatment:
opening) and tracks to the external opening, usually the site of o Fistulotomy (opening the fistulous tract), curettage, and
prior drainage. healing by secondary intention
o The internal opening is usually located at the dentate
line. III-A-2. TRANSPHINCTERIC FISTULA
o Tracts connect the internal and external openings to each
other.  Often results from an ischiorectal abscess and extends through
While majority of fistulas are cryptoglandular in origin, trauma, both the internal and external sphincters
Crohn’s disease, malignancy, radiation, or unusual infections  Very complex and rare
(TB, actinomycosis and chlamydia) may also produce fistulas.  Also called horseshoe fistula
A complex, recurrent, or nonhealing fistula should raise the  Pathway:
suspicion of one of these diagnoses. o Internal opening in the posterior midline and extend
There are physicians that give antibiotics. Do not give anteriorly and laterally to one or both ischiorectal spaces
antibiotics by way of the deep post-anal space
III-A. CLASSIFICATION OF FIA o Track passes from one fossa to the contralateral one
through the posterior rectum
 Treatment:
o <30% of the sphincter muscles involved: sphincteroctomy
o High transphincteric fistulas (more muscle involved):
seton

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bb A seton is a drain placed through a fistula to maintain drainage Figure 11: Salmon and Goodsall’s rule to identify internal
and/or induce fibrosis. openings of FIA. Divide the anal opening at this level using an
Treatment of transsphincteric fistula depends on the location imaginary line, bisecting it anteriorly and posteriorly. Patient is
of the sphincteric complex. usually in prone jack knife position.

III-A-3. HIGH TRANSSPHINCTERIC FISTULA
 Originates in the intersphincteric plane and tracks
up and around the entire external sphincter
 Treatment:
o Usually treated with seton placement
 Fistulas are categorized based upon their relationship to the
anal sphincter complex, and treatment options are based upon
these classifications
o This is important when placing your metal probes so you
will know where to direct them and prevent false tract
formation

III-A-4. EXTRASPHINCTERIC FISTULA Table 2. Summary of Salmon and Goodsall’s Rule.

Direction to the Internal
 Originates in the rectal wall and tracks around both External Opening
Opening
sphincters to exit laterally, usually in the ischiorectal fossa
Anterior external opening < 3cm Connect to the internal opening
 Pathway:
from imaginary line via a short, straight, radial tract
o From rectal wall  bypasses both sphincters  exit
laterally to perineal skin Anterior external opening > 3cm Takes a detour and tracks to the
from imaginary line posterior midline
 Treatment:
o Portion of fistula outside the sphincter should be opened Posterior external opening from Connect to the internal opening
and drained imaginary line via a curvilinear fashion
o A primary tract at the level of the dentate line may also be
opened if present
o Complex fistulas with multiple tracts may require
IV. TREATMENT
numerous procedures to control sepsis and facilitate
IV-A. ANAL FISTULOTOMY
healing
o Liberal use of drains and setons  Opening of the fistulous tract
Extrasphincteric fistulas are rare, and treatment depends on
both the anatomy of the fistula and its etiology.

III-B. SALMON AND GOODSALL’S RULE

 Salmon and Goodsall’s rule can be used as a guide in
determining the location of the internal opening
 Divide the anal opening with an imaginary line dividing it into
anterior and posterior segments
 If fistula’s external opening is:
o Anterior: connects to internal opening via short radial
tract
o Posterior: connects to internal opening in posterior
midline via curvilinear tract
 Exception: Any external opening > 3cm from dentate line,
the track will go posterior and open at posterior midline
 If there are numerous openings, look at where the first burst
appeared, then follow Goodsall’s rule
Figure 12: Anal Fistulotomy. Just cut above the metal probe. Few
muscles were just cut during the procedure.
Cannot be done if the fistula tract rotates ABOVE the
external anal sphincter.
o Because it can result to incontinence if the External Anal
Sphincter is cut.
 Only 30% of the external anal sphincter can be
cut/removed.
 If >30% is cut, patient can have incontinence with
loose stools.
We can adjust without an INTERNAL ANAL SPHINCTER.
Puborectalis muscle SHOULD NOT BE CUT
o If done, it may result to incontinence with SOLID stools

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bb
Fi
gure 13: Anal fistulotomy with bilateral external opening. Open
up the tract, and create a V-Shaped wound. Then the granulation
tissue will start to fill up the gap. Then the skin will start to grow
over the granulation tissue.
 Fistulotomy dissecting Puborectalis muscle would result to:
1. Deep wound
2. Incontinence
3. Constant further contamination of flowing stool in the v-
shaped fistulotomy wound
Figure 14: Horseshoe Fistula-In-ano. Only 1 internal opening
which in this image is in the posterior midline. Both areas has
external opening. It also shows a lot of dirt (term used by the
lecturer, referring to the pus/necrotic tissue) under the skin.
Figure 15: Fistula-In-Ano with multiple external opening. There is
only 1 internal anal opening.
 INTERNAL OPENING – culprit why Fistula- In-Ano won’t heal.
 WHAT IF, we just:
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o Close the internal opening – stool won’t pass in the
opening, resulting to the following:
 Discontinuing the constant contamination
 However, there is remaining dirt under the skin 
which will eventually progress.
 The dirt may progress and push in the internal
opening  opening the internal opening again
o Better to first clean all the dirt, let it heal ,and then do the
different options.
 Constant contamination of the tract will NOT be prevented
with antibiotics alone or if surgery is not performed.
 Perimeter Fence-saving surgery
o Endorectal Advancement Flap
o Lift Procedure
o Anal Fistula Plug
IV-B. DIFFERENT OPTIONS TO CLOSE THE INTERNAL
OPENING
IV-B-1. ENDORECTAL ADVANCEMENT FLAP
Figure 16: Endorectal Advancement Flap (above from ppt,
below from Schwartz)
Low and mid-rectovaginal fistulas are usually best treated with
endorectal advancement flap.
4.01.b Perianal Abscess [Dr. Azares]

bb Principle: Based on the advancement of healthy mucosa,

submucosa, and circular muscle over the rectal opening (the
high-pressure side of the fistula) to promote healing
Get the skin in the rectum, pull it on and plaster it in the
internal opening.

PREDICTORS OF POOR OUTCOME

 Undrained sepsis
 Previous irradiation Figure 18: Anal fistula plug. It is inserted through the internal
opening. The fistula tract is filled with the plug
 Diameter >2.5cm
 Fistula present fewer than 6 weeks
 Lyophilized pocrine intestinal submucosa
 Active Crohn’s proctitis
 Not available in the Philippines
 The plug will promote granulation tissue formation, which will
IV-B-2. LIFT PROCEDURE eventually fill up the fistula tract so you don’t have any wound.
 Only done with tracts WITHOUT abscess and simple tract.
 LIFT = Ligation of the Intersphincteric Fistula Tract
In this procedure, the fistula is identified in the intersphincteric
plane (usually by placement of a lacrimal probe), divided, and IV-B-4. SETON
the two ends ligated.
Bridging the gap for a more definitive procedure
Put drainage
Inserted to decrease the induration, and to “mature” the fistula
tracts
 It is a circular drain.
 Placed from the external fistula opening in the skin, through
the tract and internal opening and brought out of the anal
canal. It is tied to itself as a loop. (RUSH, 2013)
 Allows the fistula and any associated cavity to drain and to
shrink down.
 Keeps the tract and external site open so that a new abscess is
less likely to develop.

Figure 17: LIFT Procedure. (1). Identification of the tract (2).

Opening of the intersphincteric space (3). Isolation of the fistula tract
and (4). Ligation of fistula tract

 First, identify the location of the tract.

 Look for the “straw”/tract near the internal opening

(This section is lifted from 2018A trans):

 Go in between the external and internal anal sphincters and Figure 19: Seton. (1) Multiple perianal fistulas and extensive
separate them. Once separated, you will be able to see the perianal induration after multiple (failed) procedures (see radial
tract because it traverses the external and internal sphincters. incision in the right gluteal region) (2) Six weeks later, the
You are not going to cut a muscle! induration has resolved, and the patient returns for surgery for
o This will result to 0% rate of incontinence definitive fistula closure. (3) six weeks following surgery, all drainage
 Once the tract is identified, clump distally and proximally then had resolved.
cut between the clumps and ligate the tract.
 Small wound is created compared to the huge and lengthy
fistulotomy wound. (Azores, 2016)
.
IV-B-3. ANAL FISTULA PLUG / BIPROSTHETIC PLUG

(This section is lifted from 2018A trans)

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bb GUIDE QUESTIONS
1. One of the following items is correct in describing the
usefulness of the Salmon and Goodsall’s rule:
A. It helps in deciding whether anal fistulotomy or seton
placement will be done.
B. It helps in localization of the course of the fistula tract
C. It helps in determining the causative bacterial flora in
perianal abscess
D. It helps in prognosticating the results of treatment

2. What is the reason for non-healing of fistula in ano?

A. Inadequate antimicrobial coverage
B. Presence of immunosuppressive condition
C. Constant contamination of the tract
D. Uncontrolled diabetes

3. On perianal inspection, an external opening was located near

the coccygeal bone. A diagnosis of fistula in ano was made.
Where is the internal opening?

A. Posterior midline along the dentate line

B. Anterior midline along the dentate line
C. Right lateral alongthe dentate line
D. Left lateral along the dentate line

4. What is the most common cause of fistula in ano?

A. Cryptitis
B. Crohn’s disease
C. Ulcerative colitis
D. Folliculitis

5. If the external opening is located at the anal verge, the course

Figure 20: Seton Surgery. You have multiple external opening and of the tract is most probably
stool is coming out from one of the openings. Remember what is A. Interspincteric
happening under the gluteal area. This might be a huge abscess. B. Transphincteric
You cannot just do anal fistulotomy because it is a high
C. Suprasphincteric
transphincteric FIA. When you open up the tract, you cut the
puborectalis, external and internal anal sphincters and the spaces D. Extrasphincteric
are full of abscesses, consequently you render the patient
incontinent, hence fistulotomy is not indicated. You cannot also do 6. What is the minimum amount of intraluminal volume in the
LIFT because the tract is friable. Endorectal advancement flap is not rectum that will initiate the urge to defecate
also possible because the infected area will just push out the flap. A. 30 ml
So, first, seton placement until the wound is slowly healed. The B. 60 ml
wound decreases in size and you remove the seton one by one until C. 120 ml
such time the wounds would close then that is the time you do
D. 240 ml
definitive surgery (whether LIFT or flap). This is the end result of the
drain (bottom-right), there’s one more seton there. This case took 4
7. Fine continence of the anus is due to the physiologic function
– 5 months of constant bringing the patient inside the OR on an
outpatient basis just to clean those small cavities. (lifted from 2018A of the
trans) A. Anal cushion
B. Internal anal sphincter
C. External anal sphincter
REFERENCES D. Puborectalis muscle

th
Schwartz (10 Edition)
8. A 56 year-old patient with uncontrolled diabetes for five years
 2018A trans
came in the emergency room due to painful and swollen
 https://www.rush.edu/sites/default/files/Surgery-Fistulas-
perianal margin. The best treatment of choice is
2013.pdf

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bb A. Emergency admission and administration of intravenous

broad spectrum antibiotics
B. Emergency admission and insulin infusion
C. Emergency incision and drainage
D. Hot sitz bath and intravenous pain killer

9. Differentiation between perianal abscess and ischiorectal

abscess is made by
A. Rectal exam
B. Inspection
C. Endorectal ultrasound
D. CT scan

10. A 35 year-old patient came in the ER due to persistent perianal

discharge three months after he underwent incision and
drainage for ischiorectal abscess. What is the reason for
persistent perianal discharge?
A. Failure to administer antibiotics after the incision and
drainage
B. Failure to identify associated medical problem
C. Constant contamination of the anal glands
D. Inadequate drainage

11. One of the following is a contraindication for rectal

examination?
A. Anal tenderness
B. HIV/AIDS
C. Condyloma acuminatum
D. Injury to the anal sphincter muscles

B, C, A, A, A, A, A, C, B, C, A

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