20/8/2017 Diagnosis: Perianal Abscess with Fistula : Emergency Medicine News

Diagnosis: Perianal Abscess with Fistula

Filippone, Lisa M. MD

Emergency Medicine News: July 2005 - Volume 27 - Issue 7 - p 18

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Dr. Filippone is an assistant professor of emergency medicine at Drexel University College of Medicine and the
director of the division of emergency ultrasound at Mercy Hospital of Philadelphia.

Continued from p. 13 This patient did indeed have an incision and drainage of a perianal abscess done in the ED the
year before. Unfortunately for this patient, a fistula formed and now he is presenting with a recurrent perianal
abscess. Notice the small amount of granulation tissue protruding onto the skin surface which is often seen with
fistula formation. He was seen by general surgery in the ED. Given his presentation and the small superficial
location of this abscess, an I&D in the ED was done by surgery. Packing was placed within the cavity, and the patient
was placed on oral antibiotics. He was scheduled for follow-up in the surgical clinic 48 hours later. At that time, they
planned to discuss further management of the fistula.

Perirectal abscesses are not uncommon in the ED. The majority of these abscesses are believed to be the result of
occluded anal glands with secondary bacterial infection. The anal glands originate in the intersphincteric space. The
ducts from these glands penetrate through the internal sphincter and end in the anal crypts at the dentate line.
Classification of perirectal abscesses are based on the spread and location of subsequent infection. If the spread of
infection is distally into the perianal skin, the abscess is referred to as perianal. This is the most common type of
perirectal abscess.

It is often seen in otherwise healthy adults, often men in their fourth decade. If the abscess is small and localized
and the patient has no other co-morbid conditions, local I&D may be done in the ED with follow-up in 48 hours.
Care must be taken to recognize fully the extent of cavity formation. If local anesthesia is inadequate to evaluate the
area fully, admission for drainage in the OR is appropriate. One must be mindful of the location of the sphincters
because incontinence is a possible complication. Along with incontinence, fistula formation is a potential
complication. This is fairly common, and may occur in as many as 30 percent to 50 percent of patients. Because of
these complications, some physicians feel surgery should be involved in most of these cases.

An ischiorectal abscess forms when the direction of spread of an infected anal gland is through the external anal
sphincter laterally into the ischiorectal space. This is the second most common type of perirectal abscess. Patients
may present with fever, chills, and rectal pain. An area of erythema, induration, and tenderness with possible
fluctuance is present within the buttock. These can be unilateral, but if there is extension into the deep post anal
space, bilateral abscesses may be seen. This is referred to as a horseshoe abscess.

If infection remains localized within the space between the internal and external sphincters, an intersphincteric
abscess results. There are usually no external findings seen, and only with digital exam may a palpable tender
fluctuance be appreciated protruding into the lumen. If infection spreads superiorly above the levator ani muscle, a
supralevator abscess or pelvirectal abscess results. Like the intersphincteric abscess, there may be no outer physical

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20/8/2017 Diagnosis: Perianal Abscess with Fistula : Emergency Medicine News

exam findings seen with this type. On digital exam, it may be possible to palpate a tender indurated area above the
anal ring. There is some debate over this type of abscess. While some feel it originates from infected anal glands,
others feel it results from another pelvic or abdominal process such as a complication of PID, diverticulitis, or
inflammatory bowel disease.

Appropriate treatment of perirectal abscesses and fistulas begins with correctly identifying the location and extent
of infection. Most perirectal abscesses should have some type of imaging performed. The only exception to this
would be small, well localized, superficial perianal or ischiorectal abscess which may lend itself to local I&D. CT
scanning with contrast is usually the test of choice. Evaluation of fistulas is more complex. While some prefer direct
surgical exploration, the use of other imaging modalities may be beneficial. Traditionally fistulography was used to
image fistula tracts, but the accuracy of this test is poor. Unlike in perirectal abscesses, CT scanning is often of little
benefit. MRI and endosonography are becoming more commonly used and have improved accuracy. Discussion
with your surgical consult along with experience in the various modalities will guide which type of imaging is
chosen.

Final treatment is surgical drainage of the abscess, which often requires the OR. Fistulas may be eradicated at that
time or at a later date once inflammation has subsided. Antibiotics are indicated if patients have extensive cellulitis
or a history of valvular abnormalities, immunosuppression, or are diabetic.

2005 Lippincott Williams & Wilkins, Inc.

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