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An anorectal abscess is a collection of pus in the anal or rectal region. It may be caused by infection of an anal fissure, sexually transmitted infections or blocked anal glands.
The following anatomical types have been identified:
- Perianal abscess: the most common (60%) - caused by direct extension of sepsis in the intersphincteric plane caudal to the perianal skin.
- Ischiorectal abscess: (20%) - results from extension of sepsis through the external sphincter into the ischiorectal space.
- Intersphincteric abscess: (5%) - depending on the effort made to find them, sepsis confined to the intersphincteric space.
- Supralevator abscess: (4%) - produces horseshoe abscess track.
- Postanal abscess: posteriorly based below the level of the ano-coccygeal ligament.
- High-risk groups include those with diabetes, immunocompromised patients, people who engage in receptive anal sex and patients with inflammatory bowel disease.
- Deep rectal abscesses may be caused by intestinal disorders such as Crohn's disease or diverticulitis.
- Studies suggest that most patients are between the ages of 20 to 60 with a mean age of 40. The male-to-female ratio is 2:1.
- Symptoms include painful, hardened tissue in the perianal area, discharge of pus from the rectum, a lump or nodule, tenderness at the edge of the anus, fever, constipation or pain associated with bowel movements.
- The perianal pain is usually constant, throbbing and worse when sitting down.
- A rectal examination may confirm the presence of an anorectal abscess.
- Superficial perianal abscesses may occur in infants and toddlers. The abscess often appears as a swollen, red, tender lump at the edge of the anus. The infant may have discomfort but no other symptoms.
- A digital rectal examination is usually sufficient for the diagnosis and the treatment planning of anal abscesses and fistulae.
- Initial investigation will depend on presentation but may include a screen for sexually transmitted diseases and/or investigation for inflammatory bowel disease, diverticular disease or lower gastrointestinal tract malignancy.
- Proctosigmoidoscopy may be performed to exclude associated diseases.
- MRI scan: allows the assessment of:
- Location of any fistular tracts.
- Location of the internal and external opening(s) of any fistula.
- Location of deep abscesses.
- The state of the anorectal wall and the perirectal spaces.
- Any damage to the anal sphincter.
- Transperineal ultrasound may be a useful adjunct.
Fistula in ano
- Fistulae occur in approximately 40% of patients with anorectal abscesses. Anorectal fistulae may also be associated with diverticular disease, inflammatory bowel disease, malignancy, tuberculosis and actinomycosis.
- One study found that 68% of recurrent abscesses were associated with a fistula.
- Goodsall's rule: an external opening situated behind the transverse anal line will open into the anal canal in the midline posteriorly. An anterior opening is usually associated with a radial tract.
- Fistulae may be classified as intersphincteric (25% in one study), trans-sphincteric (29.16%), suprasphincteric (8.33%), extrasphincteric (12.5%). Extrasphincteric fistulae are usually not associated with intersphincteric sepsis.
- Prompt surgical drainage.
- Medication for pain relief.
- Antibiotics are usually not necessary unless there is associated diabetes or immunosuppression.
- A Cochrane review found that fistula surgery with abscess drainage significantly reduced recurrence or persistence of abscess/fistula, or the need for repeat surgery, compared to abscess drainage alone.
- Low fistulae: lay open with either fistulotomy or fistulectomy.
- High fistulae: may require a defunctioning proximal colostomy; there is also a risk of postoperative faecal incontinence.
- An advancement flap (a section of mucosa removed from the anal lining) may be used to close the defect once the fistula post-fistulectomy.A biosynthetic anal fistula plug has been developed but the National Institute for Health and Care Excellence (NICE) recommend its use only as part of a clinical trial, due to lack of evidence supporting efficacy.
- Clinical trials assessing adipose stem cells, collagen, dermal matrix and numerous other techniques are ongoing.
- Systemic infection.
- Fissure in ano occurs in up to 30% of patients (the risk is reduced by early surgical drainage).
- The outcome is good if the abscess is treated promptly.
- One study found that 31% of patients who had incision and drainage of perianal abscess developed a fistula. Patients aged under 40 years and patients without diabetes seemed to be at higher risk. Perioperative antibiotics significantly reduced the rate of subsequent fistula formation.
- Fistula in ano in children often resolves spontaneously and immediate surgical treatment should be withheld.
Further reading and references
Lewis RT, Maron DJ; Anorectal Crohn's disease. Surg Clin North Am. 2010 Feb90(1):83-97, Table of Contents.
Abcarian H; Anorectal infection: abscess-fistula. Clin Colon Rectal Surg. 2011 Mar24(1):14-21. doi: 10.1055/s-0031-1272819.
Nevler A, Beer-Gabel M, Lebedyev A, et al; Transperineal ultrasonography in perianal Crohn's disease and recurrent cryptogenic fistula-in-ano. Colorectal Dis. 2013 Aug15(8):1011-8. doi: 10.1111/codi.12204.
Sofic A, Beslic S, Sehovic N, et al; MRI in evaluation of perianal fistulae. Radiol Oncol. 2010 Dec44(4):220-7. doi: 10.2478/v10019-010-0046-4. Epub 2010 Oct 14.
Malik AI, Nelson RL, Tou S; Incision and drainage of perianal abscess with or without treatment of anal fistula. Cochrane Database Syst Rev. 2010 Jul 7(7):CD006827. doi: 10.1002/14651858.CD006827.pub2.
Kim do S; Comparison of a fistulectomy and a fistulotomy with marsupialization in the management of a simple anal fistula: a randomized, controlled pilot trial. J Korean Soc Coloproctol. 2012 Apr28(2):67-8. doi: 10.3393/jksc.2012.28.2.67. Epub 2012 Apr 30.
Jordan J, Roig JV, Garcia-Armengol J, et al; Risk factors for recurrence and incontinence after anal fistula surgery. Colorectal Dis. 2010 Mar12(3):254-60. doi: 10.1111/j.1463-1318.2009.01806.x. Epub 2009 Feb 7.
Christoforidis D, Pieh MC, Madoff RD, et al; Treatment of transsphincteric anal fistulas by endorectal advancement flap or collagen fistula plug: a comparative study. Dis Colon Rectum. 2009 Jan52(1):18-22. doi: 10.1007/DCR.0b013e31819756ac.
Closure of anorectal fistula using a suturable bioprosthetic plug; NICE Interventional Procedure Guideline (November 2011)
Anal fistula - clinical trials; NHS Choices, 2014
Lohsiriwat V, Yodying H, Lohsiriwat D; Incidence and factors influencing the development of fistula-in-ano after incision and drainage of perianal abscesses. J Med Assoc Thai. 2010 Jan93(1):61-5.
Afsarlar CE, Karaman A, Tanir G, et al; Perianal abscess and fistula-in-ano in children: clinical characteristic, management and outcome. Pediatr Surg Int. 2011 Oct27(10):1063-8. doi: 10.1007/s00383-011-2956-7.