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Perianal abscess

Article  in  British Medical Journal (Clinical research ed.) · February 2017

DOI: 10.1136/bmj.j475

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Kapil Sahnan Samuel Adegbola

Imperial College London St. Mark's Hospital (RF) and Imperial College London (HCL)
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Philip J Tozer Josef S Watfah

Imperial College London London North West Healthcare NHS Trust
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BMJ 2017;356:j475 doi: 10.1136/bmj.j475 (Published 2017 February 21) Page 1 of 6

Practice

PRACTICE

CLINICAL UPDATES

Perianal abscess
1
Kapil Sahnan specialist registrar in colorectal surgery , Samuel O Adegbola specialist registrar in
1 1
colorectal surgery , Phillip J Tozer specialist registrar in colorectal surgery , Josef Watfah consultant
2
emergency surgeon , Robin KS Phillips professor of colorectal surgery, consultant surgeon and
1
clinical director of St Mark’s Hospital
1
Imperial College Faculty of Medicine, St Marks Hospital, London SW7 2AZ, UK; 2Northwick Park Hospital, London, UK

The annual incidence of perianal abscess is estimated between presentations of abscesses are perianal (up to 60%) and
14 000 and 20 000 people in the UK, resulting in about 12 500 ischiorectal.6 10
operations in the NHS each year.1 A recent Swedish cohort study Rarer causes include abdominal or pelvic infections (such as
estimated the incidence at 16.1 per 100 000.2 The true incidence from diverticulitis), direct penetration of the anal wall (by
may be higher, since many patients are treated with antibiotics chicken or fish bones or by anal digitation), perforation from
in the community and some abscesses spontaneously regress or low rectal or anal cancers, penetrating ulcers,11 tuberculosis,12
discharge.2 3 Patients usually present with an erythematous and actinomycosis.13 There is no evidence that abscesses are
swelling near the anus and may be embarrassed or reluctant to related to personal hygiene or sedentary lifestyles.14
seek treatment. They may present to a non-specialist in the first
instance. This article provides information on the causes and
different types of perianal abscess and an update on how they
How do they present?
are best managed. Superficial abscesses present acutely as tender, localised,
What are perianal abscesses? erythematous swellings, and some may present with discharge
(fig 2⇓). Ischiorectal abscesses may take longer to become
An abscess is a localised collection of infected fluid. Although visible externally. They may present with vague pelvic or
there are strict anatomical definitions for the different anorectal perianal pain and fever, and on examination the buttock may
abscesses, initial management is the same in most cases and the be red and indurated compared with the unaffected side. Digital
term “perianal abscess” is generally used as a result (fig 1⇓). rectal examination can be painful in the acute setting and can
About 90% of idiopathic perianal abscesses occur because of be postponed until examination under anaesthesia if appropriate
infection of the cryptoglobular glands.4 5 Most occur posteriorly Deep abscesses are often harder to diagnose. Patients may
and in the intersphincteric space, where the anal glands are present with sepsis, even though there are no visible signs.
located.6 Abscesses are classified as superficial or deep in Imaging may be required to confirm the diagnosis in these cases.
relation to the anal sphincter. If the infection bursts through the A combination of systemic sepsis and a clinical history of recent
external sphincter, it will form an ischiorectal abscess. If it pelvic infections, Crohn’s disease, or previous anorectal sepsis
spreads laterally on both sides it can form a collection of sepsis, may point to an underlying deep abscess.
which forms a ‘horseshoe’ around the sphincters. Superior When examining a patient with anal symptoms look for signs
extension (supralevator abscess) beyond the puborectalis or the suggestive of alternative pathology, including fissures or
levators is rare and may represent iatrogenic injury (such as thrombosed haemorrhoids. Sexually transmitted infection can
inadvertent injury from a fistula probe). also present with anal lesions and pain, as can malignancy.

Who gets perianal abscesses? Abscess or fistula?

Perianal abscesses are twice as common in men as in women, In about a third of patients, a fistula is found either at the time
with a mean age of 40 years in both sexes.7 8 Known risk factors or subsequent to abscess drainage.10-16 Most fistulas arise on the
associated with developing an abscess include inflammatory background of a pre-existing abscess.17 They may also occur
bowel disease, smoking, and HIV infection.9 The most common spontaneously and (less commonly) in the context of

Correspondence to: K Sahnan ks303@doctors.org.uk

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BMJ 2017;356:j475 doi: 10.1136/bmj.j475 (Published 2017 February 21) Page 2 of 6

PRACTICE

What you need to know

• Perianal abscesses almost always require surgical drainage, even if they have spontaneously discharged
• Patients with diabetes, immunosuppression, evidence of systemic sepsis, or substantial local cellulitis require urgent drainage
• In uncomplicated cases, offer incision and drainage within 24 hours
• Drainage leads to an open cavity that typically takes 3-4 weeks to heal
• Persistent failure to heal may indicate an underlying fistula

inflammatory bowel disease, tuberculosis, trauma, or as a evident the patient should be offered a faecal calprotectin assay
complication of local surgical procedures (such as and referral to a gastroenterologist for endoscopic evaluation.
haemorrhoidectomy or episiotomy). Most abscesses are drained externally, but occasionally deep
There is no definitive means of preventing or predicting fistula internal abscesses are drained into the anal canal.
occurrence or formation after abscess drainage. It was initially In cases of severe pain without objective evidence of an abscess
thought that detection of enteric organisms in the perianal (and in the absence of another cause such as an anal fissure or
abscess was associated with an increased risk of subsequent a thrombosed haemorrhoid) at examination under anaesthesia,
fistula formation.18 However, a recent case series of 164 patients consider magnetic resonance imaging. Endoanal ultrasound is
found no statistically significant association between the used in some centres to assess for perianal fistula, but its role
presence of gut-derived organisms and the development of a is limited by pain in the acute setting.
fistula (odds ratio 0.48 (95% confidence interval 0.17 to 1.37)) A retrospective consecutive series of 500 patients with perianal
or recurrence of perianal abscess (odds ratio 1.66 (0.46 to abscesses found a re-operation rate of 7.6% (within 10 days of
6.01)).19 the operation) and concluded that the commonest reasons for
Furthermore, a multicentre, double-blinded randomised trial these were incomplete drainage, premature skin closure, and
showed that antibiotic treatment after abscess drainage offered missed loculations (rare in perianal abscesses).25
no protection against subsequent fistula formation.20 In spite of evidence suggesting that treating an associated fistula
in the acute setting reduces subsequent recurrence,26 there is
How are abscesses managed? insufficient consensus to support surgeons undertaking
immediate fistula treatment at incision and drainage of perianal
In the community abscesses, particularly if they are less experienced.
Offer early referral to a surgical team for discussion of incision
and drainage, and avoid prescribing trials of antibiotics in the Postoperative management
community. The Royal College of Surgeons’ guidelines on
After incision and drainage, the aim of treatment is to allow the
emergency surgery recommend that abscesses are ideally drained
cavity to heal by secondary intention. The options for managing
within 24 hours.21 A double-blind randomised controlled trial
the cavity are packing the wound (fig 3⇓) or leaving the cavity
and a prospective clinical trial found that the addition of
open (fig 4⇓), with or without digitation (where the patient rubs
antibiotics to drainage does not improve healing rates or reduce
the base of the wound) (table 1⇓). A systematic review of two
recurrence.22 23 Because of the risk of deep infection, sepsis, and
randomised control trials found no evidence to support packing
necrotising soft tissue infection, patients who are
or non-packing, with respect to healing or quality of life.29 A
immunosuppressed, have diabetes, or have evidence of systemic
recent multicentre observational study of 141 patients from the
sepsis or cellulitis require urgent drainage on the day of
UK found that packing was costly and dressing changes were
presentation.
associated with a twofold to threefold increase in pain scores.30
Whichever approach is used, monitor the wound for worsening
Incision and drainage symptoms, persistent or spreading cellulitis, malaise or pyrexia,
Manage those with evidence of sepsis according to the “sepsis and inflammatory markers and discuss with the surgical team
six” guidelines,24 and treat the abscess with drainage of the in the presence of any of these symptoms.
trapped perianal sepsis. If the abscess is clinically evident,
imaging is rarely required. Incision and drainage can be Follow up
performed under general anaesthesia or local anaesthesia
Patients with their first perianal abscess in the absence of
depending on the complexity of the case and patient preference.
underlying disease can be discharged after drainage with advice
Local anaesthesia is generally less effective in the presence of to present to clinic if their abscess fails to heal, which refers to
inflammation but is preferred in superficial abscesses or in ongoing discharge, suggesting the presence of a fistula. Routine
pregnancy. Incision and drainage are performed after infiltration incision and drainage of uncomplicated anorectal abscesses do
of the area with 1% lidocaine. Ethylene chloride spray can be not require postoperative antibiotics—a randomised, controlled,
used to numb the area immediately before infiltration. multicentre trial showed no significant shortening of the healing
If general anaesthesia is chosen, this allows for a detailed time or any reduction in recurrence rate with antibiotics.31
examination under anaesthesia, which includes an assessment However, antibiotics may be of benefit in patients with systemic
of the anorectum with a rigid sigmoidscope and exploration of symptoms, extensive cellulitis, or underlying
the abscess cavity. Examination findings that may suggest an immunosuppression.32
underlying cause for the abscess such as Crohn’s disease include Offer patients with recurrent abscesses a review appointment
proctitis, strictures, ulcers, fissures or complex or recurrent with a surgeon for further investigation and treatment of any
abscess drainage, and fistulas. Measurement of faecal underlying fistula. If there is evidence of underlying conditions
calprotectin may be useful, as elevated calprotectin suggests (such as Crohn’s disease and hidradenitis suppurativa) refer to
inflammation within the intestine and may aid with diagnosis an appropriate specialist for treatment.
of Crohn’s disease. Thus, if the above examination features are

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BMJ 2017;356:j475 doi: 10.1136/bmj.j475 (Published 2017 February 21) Page 3 of 6

PRACTICE

Special circumstances: Crohn’s disease 13 Fry GA, Martin WJ, Dearing WH, Culp CE. Primary actinomycosis of the rectum with
multiple perianal and perineal fistulae. Mayo Clin Proc 1965;356:296-9.pmid:14280550.
Perianal abscesses are a potential complication in Crohn’s 14 Read DR, Abcarian H. A prospective survey of 474 patients with anorectal abscess. Dis
Colon Rectum 1979;356:566-8.. doi:10.1007/BF02587008 pmid:527452.
disease. Chronic immunosuppression, loose stools, and poor 15 Vasilevsky CA, Gordon PH. The incidence of recurrent abscesses or fistula-in-ano following
wound healing in this population make perianal sepsis treatment anorectal suppuration. Dis Colon Rectum 1984;356:126-30.. doi:10.1007/
BF02553995 pmid:6697831.
challenging. A retrospective study of 7218 patients with a 16 Henrichsen S, Christiansen J. Incidence of fistula-in-ano complicating anorectal sepsis:
perianal abscess or fistula found the complication rate was 24% a prospective study. Br J Surg 1986;356:371-2. doi:10.1002/bjs.1800730515 pmid:
3708285.
in patients with underlying Crohn’s disease compared with 4.8% 17 Nelson R. Anorectal abscess fistula: what do we know?Surg Clin North Am
for idiopathic cases, and patients with Crohn’s disease had longer 2002;356:1139-51, v-vi.. doi:10.1016/S0039-6109(02)00063-4 pmid:12516844.
operating times and hospital stays.33 18 Grace RH, Harper IA, Thompson RG. Anorectal sepsis: microbiology in relation to
fistula-in-ano. Br J Surg 1982;356:401-3. doi:10.1002/bjs.1800690715 pmid:7104611.
Evaluate and treat patients presenting with Crohn’s abscesses 19 Xu RW, Tan K-K, Chong C-S. Bacteriological study in perianal abscess is not useful and
not cost-effective. ANZ J Surg 2016;356:782-4.pmid:27226422.
promptly to minimise the risk of sepsis related complications, 20 Sözener U, Gedik E, Kessaf Aslar A, et al. Does adjuvant antibiotic treatment after drainage
which can be exacerbated in patients receiving of anorectal abscess prevent development of anal fistulas? A randomized,
placebo-controlled, double-blind, multicenter study. Dis Colon Rectum 2011;356:923-9.
immunosuppressive treatment.34 Crohn’s abscesses are more doi:10.1097/DCR.0b013e31821cc1f9 pmid:21730779.
often associated with fistulas. Antibiotic therapy is used in cases 21 Royal College of Surgeons. Emergency surgery: standards for unscheduled surgical care.
2011. www.rcseng.ac.uk/library-and-publications/college-publications/docs/emergency-
of systemic sepsis and has been used in combination with the surgery-standards-for-unscheduled-care/.
patient’s normal immunomodulators.35 36 22 Llera JL, Levy RC. Treatment of cutaneous abscess: a double-blind clinical study. Ann
Emerg Med 1985;356:15-9. doi:10.1016/S0196-0644(85)80727-7 pmid:3880635.
Patients with underlying Crohn’s disease are best managed under 23 Macfie J, Harvey J. The treatment of acute superficial abscesses: a prospective clinical
the joint care of colorectal surgeons and gastroenterologists. As trial. Br J Surg 1977;356:264-6. doi:10.1002/bjs.1800640410 pmid:322789.
24 Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign Guidelines Committee
with idiopathic cases, patients with perianal abscess should have including the Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines
an examination under anaesthesia, and when possible this should for management of severe sepsis and septic shock: 2012. Crit Care Med
2013;356:580-637.. doi:10.1097/CCM.0b013e31827e83af pmid:23353941.
be performed by a surgeon experienced in proctology, as the 25 Onaca N, Hirshberg A, Adar R. Early reoperation for perirectal abscess: a preventable
abscesses are often associated with fistulas. complication. Dis Colon Rectum 2001;356:1469-73. doi:10.1007/BF02234599 pmid:
11598476.
26 Malik AI, Nelson RL, Tou S. Incision and drainage of perianal abscess with or without
Contributors: KS, SA, and PJT conducted the literature review. KS, SA, treatment of anal fistula. Cochrane Database Syst Rev 2010;(7):CD006827. pmid:
and JW wrote the article, and RKSP reviewed the article and made 20614450.
27 Tonkin DM, Murphy E, Brooke-Smith M, et al. Perianal abscess: a pilot study comparing
amendments. KS and RKSP are the guarantors. packing with nonpacking of the abscess cavity. Dis Colon Rectum 2004;356:1510-4.. doi:
10.1007/s10350-004-0620-1 pmid:15486749.
Competing interests: We have read and understood BMJ policy on
28 Perera AP, Howell AM, Sodergren MH, et al. A pilot randomised controlled trial evaluating
declaration of interests and have no relevant interests to declare. postoperative packing of the perianal abscess. Langenbecks Arch Surg 2015;356:267-71..
doi:10.1007/s00423-014-1231-5 pmid:25053508.
Provenance and peer review: Not commissioned; externally peer 29 Smith SR, Newton K, Smith JA, et al. Internal dressings for healing perianal abscess
reviewed. cavities. Cochrane Database Syst Rev 2016;(8):CD011193.pmid:27562822.
30 Pearce L, Newton K, Smith SR, et al. North West Research Collaborative. Multicentre
Patient consent obtained. observational study of outcomes after drainage of acute perianal abscess. Br J Surg
2016;356:1063-8.. doi:10.1002/bjs.10154 pmid:27061287.
31 Sözener U, Gedik E, Kessaf Aslar A, et al. Does adjuvant antibiotic treatment after drainage
1 NHS Digital. Hospital Episode Statistics, admitted patient care—England, 2014-2015.
of anorectal abscess prevent development of anal fistulas? A randomized,
www.hscic.gov.uk/hes.
placebo-controlled, double-blind, multicenter study. Dis Colon Rectum 2011;356:923-9..
2 Adamo K, Sandblom G, Brännström F, Strigård K. Prevalence and recurrence rate of
doi:10.1097/DCR.0b013e31821cc1f9 pmid:21730779.
perianal abscess--a population-based study, Sweden 1997-2009. Int J Colorectal Dis
32 Cohen JS, Paz IB, O’Donnell MR, Ellenhorn JDI. Treatment of perianal infection following
2016;356:669-73.. doi:10.1007/s00384-015-2500-7 pmid:26768004.
bone marrow transplantation. Dis Colon Rectum 1996;356:981-5.. doi:10.1007/
3 Abcarian H. Anorectal infection: abscess-fistula. Clin Colon Rectal Surg 2011;356:14-21.
BF02054685 pmid:8797645.
doi:10.1055/s-0031-1272819 pmid:22379401.
33 Causey MW, Nelson D, Johnson EK, et al. An NSQIP evaluation of practice patterns and
4 Eisenhammer S. The internal anal sphincter and the anorectal abscess. Surg Gynecol
outcomes following surgery for anorectal abscess and fistula in patients with and without
Obstet 1956;356:501-6.pmid:13360660.
Crohn’s disease. Gastroenterol Rep (Oxf) 2013;356:58-63.. doi:10.1093/gastro/
5 Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. Br J Surg
got001 pmid:24759668.
1976;356:1-12. doi:10.1002/bjs.1800630102 pmid:1267867.
34 Hyder SA, Travis SPL, Jewell DP, McC Mortensen NJ, George BD. Fistulating anal Crohn’s
6 Whiteford MH. Perianal abscess/fistula disease. Clin Colon Rectal Surg 2007;356:102-9..
disease: results of combined surgical and infliximab treatment. Dis Colon Rectum
doi:10.1055/s-2007-977488 pmid:20011384.
2006;356:1837-41.. doi:10.1007/s10350-006-0656-5 pmid:17041753.
7 Sainio P. Fistula-in-ano in a defined population. Incidence and epidemiological aspects.
35 Thia KT, Mahadevan U, Feagan BG, et al. Ciprofloxacin or metronidazole for the treatment
Ann Chir Gynaecol 1984;356:219-24.pmid:6508203.
of perianal fistulas in patients with Crohn’s disease: a randomized, double-blind,
8 Read DR, Abcarian H. A prospective survey of 474 patients with anorectal abscess. Dis
placebo-controlled pilot study. Inflamm Bowel Dis 2009;356:17-24.. doi:10.1002/ibd.
Colon Rectum 1979;356:566-8. doi:10.1007/BF02587008 pmid:527452.
20608 pmid:18668682.
9 Wei P-L, Keller JJ, Kuo L-J, Lin H-C. Increased risk of diabetes following perianal abscess:
36 West RL, van der Woude CJ, Hansen BE, et al. Clinical and endosonographic effect of
a population-based follow-up study. Int J Colorectal Dis 2013;356:235-40. doi:10.1007/
ciprofloxacin on the treatment of perianal fistulae in Crohn’s disease with infliximab: a
s00384-012-1519-2 pmid:22729713.
double-blind placebo-controlled study. Aliment Pharmacol Ther 2004;356:1329-36.. doi:
10 Ramanujam PS, Prasad ML, Abcarian H, Tan AB. Perianal abscesses and fistulas. A
10.1111/j.1365-2036.2004.02247.x pmid:15606395.
study of 1023 patients. Dis Colon Rectum 1984;356:593-7.. doi:10.1007/BF02553848 pmid:
6468199. Published by the BMJ Publishing Group Limited. For permission to use (where not already
11 Marzo M, Felice C, Pugliese D, et al. Management of perianal fistulas in Crohn’s disease: granted under a licence) please go to http://group.bmj.com/group/rights-licensing/
an up-to-date review. World J Gastroenterol 2015;356:1394-403.. doi:10.3748/wjg.v21.
permissions
i5.1394 pmid:25663759.
12 Gupta PJ. Ano-perianal tuberculosis—solving a clinical dilemma. Afr Health Sci
2005;356:345-7.pmid:16615850.

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BMJ 2017;356:j475 doi: 10.1136/bmj.j475 (Published 2017 February 21) Page 4 of 6

PRACTICE

Sources and selection criteria

We searched PubMed from 1970 to 2015 and Embase and the Cochrane Library from inception using the terms “abscess” and “perianal
sepsis” (using the Boolean operator AND) and “fistula” (using the Boolean operator OR). The reference lists were also used to identify studies
of interest. Two authors (KS, SA) independently identified publications for inclusion, and differences were resolved by discussion. We gave
priority to research published in the past five years and highly regarded older publications.

Questions for future research

• What is the true incidence of perianal abscesses and how many abscesses recur?
• What are the risk factors for fistula formation after an abscess, and how can we predict risk?
• Should we look for and treat fistulous tracts at the time of incision and drainage of abscesses?
• Does packing after drainage improve healing rates and quality of life, and is it cost effective?
• How many abscesses are a primary presentation of Crohn’s disease?

Additional educational resources

Resources for clinicians
• American Society of Colon and Rectal Surgeons. Abscess and fistula information. https://www.fascrs.org/patients/disease-condition/
abscess-and-fistula-expanded-information
• Medscape. Anorectal abscess. http://emedicine.medscape.com/article/191975-overview

Resources for patients

• Patient. Anorectal abscess. http://patient.info/doctor/anorectal-abscess

How patients were involved in this article

A patient commented on both the planning of the article and the subsequent drafts, and the article was edited in line with these comments.
Of particular concern was wound packing and the evidence for the benefits (or lack thereof) of packing the wound and dressing changes in
the community.

Education into practice

How quickly can you access specialist referral for patients with a perianal abscess?

Table

Table 1| Pros and cons of the different approaches to postoperative management after drainage of a perianal abscess

Approach Pros Cons Evidence

Packing (fig 3⇓) Prevents premature closure Costs, inconvenience, pain Observational study
Digitation No cost Painful initially, patient preference Abstract only
Open wound (fig 4⇓) No cost Potential risk of premature closure Pilot RCTs27 28

RCT = randomised controlled trial.

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PRACTICE

Figures

Fig 1 Possible sites of anorectal (“perianal”) abscesses

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PRACTICE

Fig 2 Typical clinical appearance of a superficial perianal abscess

Fig 3 Packing of wound after incision and drainage of a perianal abscess

Fig 4 Open wound after incision and drainage of a perianal abscess

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