Perianal abscesses are the most common type of anorectal abscesses. These abscesses can cause significant discomfort for patients. They are located at the anal verge and if left untreated, can extend into the ischioanal space or intersphincteric space since these areas are continuous with the perianal space. They can also cause systemic infection if left untreated.

Ninety percent of all anorectal abscesses are caused by non-specific obstruction and subsequent infection of the glandular crypts of the rectum or anus. A perianal abscess is a type of anorectal abscess that is confined to the perianal space. Other causes can include inflammatory bowel diseases such as Crohn's disease, as well as trauma, or cancerous origins.

On presentation, patients will typically complain of severe pain in the anal area, which has generally been present for several days. This is due to an infection of the anal glands, which are not adequately draining through the anal crypts. The anal glands empty into ducts that traverse the internal sphincter and drain into the anal crypts at the level of the dentate line. If not adequately draining, infection of these glands will form an abscess that can spread along several planes, such as the perianal or perirectal spaces. The perianal space surrounds the anus and is continuous with the fat of the buttock. Once a fluid collection forms, it can spread along the path of least resistance, which is typically into the intersphincteric space and other potential spaces such as the supralevator space or ischiorectal space.

Perianal abscesses are an indication for timely incision and drainage. Antibiotic administration alone is inadequate and inappropriate. Once incision and drainage are performed, there is no need for antibiotic administration unless certain medical issues necessitate the use. Such conditions include valvular heart disease, immunocompromised patients, diabetic patients, or in the setting of sepsis. Antibiotics are also considered in these patients or cases with signs of systemic infection or significant surrounding cellulitis.

• WE USUALLY GIVE A LONGITUDINAL INCISION TO FACILITATE A DEPENDANT DRAINAGE .
• ASPIRATION – 2 ADVANTEGES- COLLECTION OF PUS, INSTILLATION OF DYE TO LOCATE ANAY ANO-RECTAL CONNECTION. ( FEW ABSCESS ARE ACUTE FORM OF CHRONIC FISTULA, OR ABSCESS MAY HAVE BURST INTERNALLY)
• WE DON’T PREFER PACKING AFTER 24 HRS, AS IT DELAYS WOUND HEALING, PAINFUL TO REMOVE EVERY DAY AND DOES NOT OFFER ANY ADDED ADVANTAGE.
• PATIENT IS DISCHARGE NEXT DAY AFTER REMOVAL OF THE PACK AND LOOKING FOR ANY FRESH BLEEDING.

Incision and drainage are typically performed in the clinic setting or immediately in the emergency department. A cruciate incision is made as close to the anal verge as possible to shorten any potential fistula formation. Blunt palpation is used to ensure no other septation or abscess pocket is missed. Before completing the procedure, Packing may be placed initially for hemostasis. Continual packing may be further utilized for healing by secondary intention.

ALL PATIENTS MUST BE MADE AWARE OF THE POSSIBILITY OF DEVELOPING A FISTULA IN FUTURE WELL BEFORE THE DRAINAGE.

Patients are encouraged to keep the incision and drainage site clean. Sitz baths may assist in pain relief.
More extensive abscesses may require the operating room for the adequate exam under anesthesia to ensure adequate drainage and inspect for other diseases such as fistula in ano.
Additionally, the morbidity even in healthy patients can be significant with approximately one-third of patients developing a fistula secondary either to the disease process itself or the surgical drainage.

After treatment, the patient needs pain control, laxatives or fiber supplements to avoid constipation, and instructions on properly performing sitz baths.
Outpatient antibiotics are rarely indicated but should be considered if the patient demonstrates signs of systemic infection such as fevers or high leukocytosis. Cultures and sensitivities of the causative organism are rarely helpful.
Because of a high recurrence rate, all patients need to be followed up until there is complete healing, which may take up to 8 weeks. Additionally, up to one-third of patients may either already have a fistula in ano or develop one after their abscess, which is another reason to have a close follow-up.

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