Anorectal sepsis part I
Perianal abscesses
Background
• Anorectal abscesses and fistula = sequential phases of
the same anorectal infectious sequence
• Abscess = acute phase
• Fistula = chronic phase
• 30-70% of anorectal abscess have concomitant fistula
• 30-40% of patients develop fistula after treatment for
abscess
Coronal section of anal
canal
Sagittal section of anal
canal
Etiology
• Cryptoglandular theory (Eisenhammer)
– extension of sepsis from
intramuscular/intersphincteric anal gland when unable
to drain into anal lumen due to blocked connecting
duct across internal sphincter
• IBD
• Infectious including sexually transmitted
• Malignancy
• Iatrogenic – post-RBL, anastomotic leak
Cryptoglandular abscesses – spread
of sepsis
Horizontal/vertical Circumferential
Intersphincteric Supralevator
abscess abscess
Ischiorectal abscess
Perianal abscess
Eisenhammer classification of non-
cryptoglandular abscesses
1. Pelvirectal or
2. Submucous abscess supralevator abscess
from infected from pelvic disease
haemorrhoid,
sclerotherapy or trauma
3. Ischiorectal
abscess from primary
infection or foreign
body
5. Perianal or superficial 4. Mucocutaneous or
abscess from follicular skin marginal abscess from infected
Clinical presentation
Perianal abscess
• 2-3 days after onset,
perianal pain, +/-
constitutional symptoms
• O/E: Tender lump close to
anal margin
Clinical presentation
Ischiorectal abscess
• Present later, vague
discomfort, usually with
constitutional symptoms
• O/E: Tender induration
over ischiorectal fossa,
deep tenderness, no
erythema
Boundaries
Medial: Levator ani,
external sphincter
Lateral: Ischial
tuberosity
Superior: Levator ani
Inferior: Skin
Clinical presentation
Intersphincteric abscess
• Pain out of proportion to exam findings
• O/E: No skin changes, bogginess on DRE, feel at 3, 6, 9, 12oc
position
Supralevator abscesss
• Rectal pain, pelvic pain, urinary retention
• O/E: No external signs, induration above anorectal ring on DRE
• Assess and document continence
• Pain out of proportion also consider necrotizing soft
tissue infection
Role of imaging
• Complex abscesses with fistulae
• Induration on DRE, multiple points of tenderness on DRE
• High transsphincteric fistulae
• Recurrent disease, previous surgery
• Deeper component
• Should not replace clinical examination!
Principles of management
• Examination under anaesthesia
• Examination findings > diagnosis > management
• Inspection
• Any EO? Acutely discharging or chronic granulation tissue?
• Erythema/induration
• Palpation
• Delineate induration. Compare both sides. Using “anal clock” + relation to
hyperpigmented skin/ischial tuberosity.
• Examination with Eisenhammer to identify any IO
• Gentle probing with fistula probe to delineate course
• Red flags
• Previous surgery, recurrent abscess, anterior communication, fistula
• Female patient with anterior abscess with borderline continence
Principles of management
• Primary treatment is surgical drainage
• Identify area of most fluctuance, any unhealthy skin
• Incision as close to anal verge to minimize length of potential fistula
• Radial vs circumanal incision
• Consider wound packing/drain placement
• Factors associated with recurrence/repeated drainage
• Incomplete initial drainage, failure to break up loculations, missed
abscess, undiagnosed fistula
• Antibiotics considered in pts with significant cellulitis,
immunosuppression, concomitant systemic illness
• ASCRS guidelines suggest the above
• Some evidence that it reduces rate of fistula formation
Management of concomitant fistula
• Identification and management at time of abscess I&D = sig.
reduction in recurrence/persistence vs drainage alone (Cochrane
2010) but impact on incontinence unclear
• Primary fistulotomy (ASCRS)
• If perceived risk of incontinence is low
• Challenging to assess in severe inflammation, risk of creating false
passage
• Seton and staged fistulotomy
• Placement of seton vs fistulotomy depends on sphincter involvement
• Leave alone!
• Placement of seton = 100% fistula
Approach by site
• Perianal abscess
• Ischiorectal abscess
• Horseshoe abscess – Modified Hanley’s
• Intersphincteric abscess – internal
sphincterotomy
• Supralevator abscess
• Upward from ischiorectal = skin incision
• From pelvic process or intersphincteric = incision in rectal
wall/transanal drain to avoid creating extrasphincteric fistula
Drainage of horseshoe abscess
Treatment of horseshoe abscess with
posterior midline high transsphincteric fistula
• Classic Hanley’s procedure (1965)
• Complete division of sphincter at 6oc down to
deep post anal space – very morbid
• Lateral incisions with counter drains
• Modified Hanley’s procedure (1990)
• Placement of cutting seton in posterior midline
• Lateral incisions into ischiorectal fossae
• Drainage of bilateral ischiorectal fossae by
loose seton
Neutropenic patient
• Challenging presentation, limited erythema with
minimal to no fluctuance
• If ANC <1.0, antibiotics should be first line therapy
• Serial examination, don’t sign off too quickly
• Consider imaging to delineate extent of involvement
• With development of abscess, consider drainage
• Work with oncologists to sequence drainage with
chrmol,
