Review Article

The American Surgeon

2020, Vol. 0(0) 1–6
Treatment of Perianal Abscess and © The Author(s) 2020
Article reuse guidelines:
Fistula in Infants and Young Children: sagepub.com/journals-permissions
DOI: 10.1177/0003134820954829

From Basic Etiology to Clinical Features journals.sagepub.com/home/asu

Wei Ding1, Yao-Ran Sun1, and Zhi-Jiu Wu2

Abstract
Perianal abscess and anal fistula are 2 common anorectal diseases in infants and young children. However, their causes,
clinical diagnosis, and treatment remain controversial. Compared to adults, infants with these 2 diseases exhibit unique
clinical characteristics. Blind pursuit of conservative treatment or surgery may worsen the condition, resulting in in-
creased pain in young patients and greater economic burden and psychological harm to parents. Therefore, it is crucial to
select correct and effective treatments. This review summarizes the relevant literature from the past 10 years and
systematically explains the pathogenesis, clinical characteristics, and treatment measures of perianal abscess and anal
fistula in infants with the goal of providing clinicians a deeper understanding of perianal abscess and anal fistula in infants
and summarizing safe and effective treatment methods.

Keywords
infant, perianal abscess, anal fistula, treatment

Introduction
Perianal abscess is a purulent disease caused by acute
and chronic infection of the tissues and spaces around
the anorectum, which can infect both infants and
adults.1 Its incidence is approximately .5-4.3% of all
infants.2 Anal fistula is defined as a hollow tube lined
with granular tissue that forms an abnormal connection
between the anus and perianal skin and is associated
with a considerable incidence rate and discomfort.3
Clinically, these conditions are closely related and of-
ten regarded as 2 different periods of the same disease.
Currently, the diagnosis of perianal abscess and anal
fistula in children is mainly based on the clinical de-
scriptive features of the superficial entities that are close
to the anus. However, there are differences in size, exact
location, and relationship with the anal sphincter. In
addition, lack of potential fistula path information,
endoscopic ultrasound, or magnetic resonance imaging
(MRI) imaging research leads to confusion and varia-
tion between conservative treatment and surgical
treatment.4 Surgical treatment is still based on the
clinical skills and experience of surgeons. The choice
of the best treatment remains controversial. Consistent
data or guidelines that can effectively guide the di-
agnosis, treatment, and surgical techniques of perianal
abscess and anal fistula in infants and young children
are lacking.
Cause of Disease
To date, the actual causes of perianal abscess and anal
fistula in infants still need to be studied for the following
reasons.
Hormonal Disorder
Given the predilection for age and gender, congenital
or genetic causes can be considered.5,6 Under conditions
of androgen and estrogen imbalance, excessive androgen
and intrauterine androgen stimulates abnormal hyper-
plasia and secretions from the perianal sebaceous gland,
resulting in secondary perianal abscess and fistula in-
fection.7 One study found that peak total testosterone
levels in male infants during the first year corresponds
1
North Sichuan Medical College, Nanchong, China
2
Department of Anorectal, The Affiliated Hospital of North Sichuan
Medical College, Nanchong, China
Corresponding Authors:
Wei Ding, North Sichuan Medical College, No. 23, Tianfeng Road,
Suining, Sichuan 629000, China.
Email: WeiDing-China@outlook.com
Zhi-Jiu Wu, Department of Anorectal, The Affiliated Hospital of
North Sichuan Medical College, No. 1, Maoyuan Road, Nanchong,
Sichuan 637000, China.
Email: wzj549nc@126.com
2 The American Surgeon 0(0)
to the peak of age distribution in children with perianal
abscess, which seems to be consistent with the hypothesis
that perianal abscesses are affected by the androgen.8
However, this study also showed that when testosterone
levels reached a second peak around the age of 10-15, they
do not reach a second peak in these patients.8 Therefore,
the occurrence of perianal abscess may not be directly
related to the androgen level.
Anorectal Crypt Dysplasia
Hypoplasia of the anal crypt is the most recognized cause
to date.1,9 The anal crypt of infants is too shallow or too
deep, and the fusion of several crypts, abnormal wall
thickness, and other developmental abnormalities are
often noted.10 Congenital development of the anal crypt
causes it to be too deep, and the surrounding dentate line is
thickened. In addition, the children’s stool is not formed.
Thus, feces remain in the anal crypt and block the opening
of the anal gland, causing infection in the anal crypt that
invades into perianal tissue. These processes lead to the
formation of perianal abscess and anal fistula.
Inflammatory Bowel Disease
It has been reported that 4% of children with Crohn’s
disease may have perirectal lesions and no primary
intestinal diseases.11 About 10% of children aged 1 month-
16 years presenting with perianal abscesses and fistulas-
in-ano have been diagnosed with Crohn’s disease, directly
or later in life.12 For older children and adolescents, per-
ianal abscess and fistula may be recognized as the first
manifestation of Crohn’s disease.13 Moreover, ulcerative
colitis is also associated with perianal lesions. However,
a recent retrospective cohort study found no association
between isolated perianal abscesses with or without fistula
in the anus in children less than 2 years of age and late
Crohn’s disease in children.7 However, this study also has
some limitations. On the one hand, the research is limited to
pediatric surgery and may be subject to selection bias. On
the other hand, the follow-up time of this research is short,
so the results must be verified.
Low Immune Function
IgA can inhibit the adhesion of pathogenic microorganism
and toxins in the digestive tract. IgA synthesis begins
4-6 months after birth. Before this time, the infant mainly
relies on human milk to obtain IgA. Moreover, 89.9% of
colostrum immunoglobulin is IgA, and perianal abscess
often form during 4-6 months of age, which represent the
weakest period of intestinal immune function.14 In ad-
dition, some studies have found that men exhibit weaker
humoral and cellular immunity than women. Estrogen
enhances immunity, whereas testosterone has the opposite
effect. Thus, men are more susceptible to infectious
diseases, which may be the main reason why the majority
of infants with perianal abscess and anal fistula are
males.15
Diarrhea and Improper Care
Intestinal function in infants is imperfect with frequent
stool production or diarrhea, which makes it easy for
stool to enter the anal crypt and produce an infection. In
total, 73% of infants had a history of diarrhea before the
onset of perianal abscess.14 Infants have short anal ca-
nals, and the intestinal mucosa is easily exposed during
defecation. Repeated wiping of the anus and diaper
friction are likely to irritate and damage the rectal mu-
cosa, causing infection and the development of perianal
abscess or anal fistula.
In addition to anal gland infection, there may be other
reasons for perianal abscess or anal fistula, such as trauma,
neutropenia, malignant tumors, tuberculosis, suppurative
edema, foreign bodies, skin cysts, and radiotherapy.16
Clinical Characteristics
More than 90% of the patients were men,5,7,8,16-23 and
most of them were less than 1-year old.5,6,8,9,20,23 The
scope of abscess was generally less than 2 cm,16 and the
lesions were mainly located at 3 and 9 o’clock of li-
thotomy position6,7,9,16,20,23 that were obviously laterally
distributed. This feature may be due to the thicker sub-
cutaneous fat tissue on both sides of the anus, which is
conducive to the spread of infection. In addition, some
scholars believe that few anal crypts are located in the
anterior wall of the rectum and wide anal column spacing.
In addition, the posterior side of the rectum is not fully
developed, and the rectal angle of the anal canal is large.
The impact of feces on the posterior anal canal is limited,
and the chance of infection is reduced. Thus, the infection
is mainly found on the left and right sides.24 Some studies
using quadrant classification showed that the incidence
rate of perianal abscess and anal fistula in the fourth
quadrant was 45.9%.9
Compared with adults, complex anal fistulas are rare in
infants. In general, 1-2 fistulas are present, and the length
of fistulas is usually less than 3 cm.4 The fistulas are
straight and open to the corresponding anal sinuses, so
Solomon’s rule is not applicable to anal fistulas in infants
and young children.7 Most of the anal fistulas are low anal
fistulas, primarily including intersphincteric fistulas and
transsphincteric fistulas.4,7,24 The results of pus culture
show that the infectious bacteria of perianal abscess and
anal fistula include intestinal flora,4,5,9 skin flora,4,9 and
some mixed flora.4,16,18 Common bacteria include Escherichia
coli, Klebsiella pneumoniae, and Staphylococcus aureus.
Gender differences are also noted. E. coli is the predominant
Ding et al
bacteria in men, whereas S. aureus is more often found in
women.9
Clinical Manifestations and Diagnosis
Perianal abscess is characterized by a local mass around
the anus, redness of skin, high skin temperature, and
palpation of subcutaneous wave movement or induration,
which is usually found when parents change diapers.
Perianal abscess in infants is less likely to be associated
with systemic sepsis,5,22 but there are also cases of per-
ineum swelling and febrile convulsion caused by perianal
abscess in infants.25 Anal fistula can present as skin ul-
ceration with secretion flowing out around the anus, and
the lesion can be palpitated under the skin. Clinically,
perianal abscess is closely related to anal fistula. It is
commonly recognized that anal gland infection causes
perianal abscess and anal fistula. Approximately 20-85%
of perianal abscesses eventually develop into anal
fistulas.9,19,20 Therefore, perianal abscess and anal fistula
are not completely separate entities and are often con-
sidered as 2 periods in the same disease. Currently, the
clinical diagnosis of perianal abscess and anal fistula is
primarily based on the description of clinical character-
istics. No imaging standards based on size, location, and
relationship with the sphincter are available, especially for
complicated anal fistula. MRI exhibits high sensitivity and
specificity in the description of primary fistula and abscess
in patients with perianal disease and can be used to
evaluate fistula activity.26 However, there are dis-
advantages such as high cost, long examination time, poor
coordination in the use of infants, and may require se-
dation. Therefore, we believe that MRI is not the first
choice; it is only suitable for the diagnosis of complex
perianal diseases. Pocus is a fast, convenient, and eco-
nomical tool for evaluating perianal inflammation and
liquefying necrosis without fluctuation of palpation.27
Treatment
Conservative Treatment
Conservative management. Some studies have suggested
that some perianal abscesses in infants and young children
under the age of 1 year can heal by themselves. Con-
servative treatment avoids the need for general anesthesia
and surgery, which is the first choice for perianal abscesses
and anal fistula. Multivariate linear analysis has confirmed
that multiple lesions are an important factor affecting
conservative treatment.23 In addition, although surgery
can shorten the course of disease and reduce the risk
of abscess spread, it may increase the risk of iatrogenic
fistula formation.8 No significant difference in the re-
currence rate is observed between conservative treatment
and surgery.17 In the early stages of these diseases,
3
hygienic management, bathing, oppression of abscesses,
topical application of antibiotic ointments or anesthesia
ointments, such as compound polymyxin B ointment, and
changes in feeding methods can be employed. The cure
rate is as high as 87.3%; the median course was 23 days,
which did not differ significantly from that of abscesses
with ID 18 days) (P = .609).8 In addition, Kubota et al
used basic fibroblast growth factor spray to treat perianal
abscess and anal fistula in infants; the cytokine repaired
and remodeled damaged tissues (eg, granulation tissue
and angiogenesis) and achieved healing.28
Antibiotic use. No consensus has been reached on the use
of antibiotics. Some studies have emphasized the im-
portance of antibiotic use, arguing that antibiotics can
shorten the course of disease and reduce the incidence of
anal fistula.8,9,18,22 However, other studies believe that
antibiotics have minimal effects on the formation of anal
fistula6,17 and may even aggravate the disease.23 There are
no uniform guidelines for the use of antibiotics in clinical
practice. However, some studies suggest that the intestinal
flora is not related to the occurrence of perianal abscess
recurrence and anal fistula; thus, it is not necessary to
cultivate it.29 However, based on the results of existing
pus cultures, antibiotics currently used mainly include
β-lactam/β-lactamase inhibitors and nitroimidazoles.9,16,22
The use of antibiotics without basis is likely to cause the
production of drug-resistant bacteria, such as K. pneu-
moniae with high resistance to ampicillin and furantoin.18
Traditional medicine. Traditional medicine has gradually
become a supplement and replacement for clinical
medicine due to poor efficacy or many complications of
routine medication. Hainosankyuto (TJ-122), a tradi-
tional Kampo prescription, is a mixture of 6 herbal
extracts, including Platycodi radix, Glycyrrhizae radix,
Aurantii Fructus Immaturus, Paeoniae radix, Zizyphi
Fructus, and Zingiberis Rhizoma.30 TJ-122 has a variety
of pharmacological effects. Platycodi radix drains pus
and reduces pain. Aurantii Fructus Immaturus and
Glycyrrhizae radix reduce inflammatory infiltration.
Paeoniae Radix relieves muscle spasms and pain, and
Zizyphi Fructus and Zingiberis Rhizoma alleviate pain. TJ-
122 is used to treat children’s superficial inflammatory
abscesses in the acute stage and effectively reduces acute
inflammation and pain.30 Compared with the patients
treated by incision and drainage, patients treated with TJ-
122 experience faster suppuration, drainage, and removal
of the induration.21
Another prescription, Juzentaihoto (TJ-48), which is
also known as Shiquan Dabu Decoction in traditional
Chinese medicine, is composed of Angelicae radix, Poria,
Rehmanniae radix, Ginseng radix, Cinnamomi cortex,
Paeoniae radix, Astragali radix, Glycyrrhizae radix,
Cnidii rhizome, and Atractylodis lanceae rhizome.31
4 The American Surgeon 0(0)
Combined with TJ-122, this prescription can reduce the
recurrence rate and surgical intervention of pediatric
perianal abscess to zero. Even if the abscess ulcers during
the treatment, it can heal naturally without scarring.32
In traditional Chinese medicine, Qingreliangxue ointment
was used to treat the perianal abscess of infants, which
proved that it had a good effect of effectively reducing
swelling and analgesia and the local skin temperature of
the abscess.33
Surgical Treatment
Incision and drainage. Incision and drainage are the most
traditional and commonly performed operational proce-
dures, which are performed at the highest point of the
abscess to prevent the spread of the abscess and the
continued necrosis of surrounding healthy tissues. Gen-
eral principles for perianal drainage include the following:
use of a shallow incision, avoid damaging the sphincter,
and carefully look for anal fistula. Some studies suggest
that when the abscess exhibits wave motion for more than
4 days from the onset without perforation or diffusion
signs, it can be cut and drained.8 The use of antibiotics after
incision and drainage can effectively shorten the clinical
course and reduce the rate of abscess spread or fistula
formation.9,18 Moreover, research suggests that only deep
sedation or general anesthesia can achieve the best effect12
because the effect of local anesthesia is poor in the case of
inflammation.34 Although this method is simple and safe,
the recurrence rate is relatively high and is reported be-
tween 6.6% and 85% in the literature.6,16-18,25
Seton therapy. The principle of anal fistula treatment is to
completely open the fistula and identify the abnormal
crypt of the corresponding infection to reduce re-
currence. Pressure can be generated using a seton thread
to periodically tighten and gradually open the fistula and
sphincter. However, this procedure also causes chronic
inflammation and fibrosis, which fixes the sphincter
when it is separated and prevents the sphincter from
contracting, thereby reducing the risk of incontinence.
The cure rate of anal fistula in infants using seton therapy
is 97.2%; thus, this treatment can reduce recurrence,
effectively shorten the treatment time, and reduce pa-
rents’ concerns. In addition, anal incontinence and other
complications are not observed in long-term follow-
up.20 However, since the tightening is slight and gradual,
there is anal pain when the seton is tightening, which
usually lasts a few hours.4
Fistulotomy/Fistulectomy. Given the high recurrence rate
after incision and drainage, some scholars advocate ac-
tively identifying fistula and employing fistulotomy or
fistulectomy. The recurrence rate after fistulotomy was
only 9% in infants, which is fivefold reduced compared
with simple incision and drainage. Actively looking for
fistulas could also reduce recurrence. A recent study also
showed that the recurrence rates of incision drainage and
fistulotomy were 34.6% and 15.3%, respectively, and the
difference was significant (P = .04).35 However, some
studies have reported that after fistulectomy in adults, the
recurrence rate of anal fistula is 16%-70%, and the in-
continence rate is between 0% and 40%.36 Compared with
adults, infantile fistula is lower in position, shorter in
length, and involves less of the sphincter, which can be
easily found during the operation. A systematic evaluation
reported that the incidence of complications after fistu-
lotomy or fistulectomy in infants is only 2.6%, and no anal
incontinence was noted.37 The fistula must be completely
opened in both operations,38 but fistulotomy has the
advantages of shorter operation time and fewer compli-
cations than fistulectomy.39 Therefore, we recommend
cutting the fistula during the first operation to reduce
recurrence. During the operation, the involvement of
sphincter should be evaluated carefully, and a seton can be
placed if necessary. Care should be taken when looking
for a fistula to avoid iatrogenic fistula.
Anal fistula biologic filling therapy. In recent years, an in-
creasing number of bioengineered materials that protect
the anal sphincter have been used for the treatment of anal
fistulas in adults and children.40 The results show that
the cure rate of the treatment of anal fistula in children is
94% under the guidance of imaging. This method is in-
expensive and can be repeated.41 Fibrin glue has a 100%
success rate in treating anal fistula in children between
2 months and 12 years of age, thus avoiding fistula re-
moval or fistula incision complicated perianal pain, local
infections, and anal incontinence.7 Additionally, fibrin
glue offers better therapeutic results, especially for pri-
mary, single-channel, and low-level anal fistulas.7 The use
of an anal plug in the treatment of refractory anal fistula
in children is 72.7% effective.19 The advantage is that
the operation time is short; it can be completed within
15 minutes. In addition, there is no risk of sphincter injury.
The effect is most obvious for patients with long or
multiple anal fistulas.19
TV-assisted anal fistula treatment. This method can be used
to visually identify and determine all collaterals and intra-
anal openings of the fistula and perform electro-
coagulation and cuff closure of the fistula. Studies have
found that the use of TV-assisted anal fistula treatment in
children results in minimal pain. Moreover, the procedure
will not damage the sphincter or cause incontinence. It has
been proven to be versatile because it can be applied to
fistulas of different causes and various groups of people
including infants as well as older children and adoles-
cents, which is a backup option for ineffective surgery.42
Another systematic review of TV-assisted treatment
Ding et al
reported that video-assisted anal fistula treatment has
fewer complications in the treatment of highly complex
anal fistula and is a safe and effective method of diagnosis
and treatment.43
Summary
Regarding the treatment of perianal abscess and anal
fistula in infants and young children, numerous methods
are available that range from conservative treatment to
surgery, but the choice of treatment methods mostly de-
pends on the personal experience of the clinician. We
believe that infants and young children have a self-healing
tendency, and conservative treatment should be adopted
first. When the disease progresses, incision and drainage
are feasible and the anal fistula should be completely
opened. The degree of sphincter involvement should be
carefully evaluated during the operation to avoid sphincter
damage. According to the results of pus culture and drug
sensitivity tests, sensitive antibiotic treatment can be se-
lected. However, the existing clinical research sample size
is small, and conflicting results have been reported. No
uniform guidelines or expert consensus is available. The
choice of the best treatment remains the biggest contro-
versy in this research area. Therefore, large-scale and
multicenter prospective trials are urgently needed to verify
the efficacy of various measures and develop treatment
guidelines.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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