HWN Suggests

Anorectal Abscesses: ED Clinical Presentation, Evaluation, and Management

Perirectal abscesses can occasionally present with a tender, fluctuant mass on DRE, but may have limited physical exam findings and require imaging to diagnose. For patients with evidence of deep infection, CT is the imaging modality of choice. Transperineal ultrasound has recently been recognized as a quick, easy, noninvasive, and cost-effective technique to diagnose and monitor for resolution of anorectal abscesses.

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Articles of Interest

Perianal and Perirectal Abscess/Fistula

Perirectal abscess is different from perianal abscess. Perirectal abscess is an infection that is deep and tracks up along the rectum into the pelvis and are very rare in healthy newborns and children. These deep abscesses can be found in various locations in the pelvis and can be associated with inflammatory bowel disease, such as Crohn’s disease.

Perirectal Abscess Masquerading as Cauda Equina Syndrome

Perirectal abscesses, although considered common in younger children, are relatively infrequent in 12-year olds and are considered to be indicators of underlying inflammatory bowel disease or other serious pathologies. They are even rare as presenting pathology in the diagnosis of Crohn’s disease, occurring in only 2% to 13% of patients, which may become relevant for our patient who had not had prior symptoms of inflammatory bowel disease.

Perirectal Abscess with Anterior Extension to the Extraperitoneum and Space of Retzius

The classification of anorectal abscesses based on their location includes perianal (60%), ischiorectal (20%), supralevator and intersphincteric (5%), and submucosal (<1%), with perianal abscesses being the most prevalent [1]. Typically, these abscesses arise from anal gland infections, while perirectal abscesses are predominantly caused by cryptoglandular infections located in the small openings in the anal canal lining.

Quality Corner: Perianal and perirectal abscess

Imaging, typically a CT with IV contrast, should be performed in most of these patients to determine whether a perirectal abscess is present, in which case admission and drainage in the OR is indicated.

Under pressure: Anorectal abscesses… to drain or not to drain?

Always do a rectal exam as part of the initial evaluation. Have a low threshold to get a CT scan to define the abscess.

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StatPearls

Although often thought of as the same, perianal abscess and perirectal abscesses differ in both complexity and care options. Except for perianal abscess which can be simply incised and drained as definitive care, all others usually require intravenous antibiotics, surgical evaluation, and drainage. A majority of abscesses are diagnosed clinically based on skin findings and palpitation of the affected area alone, but some require advanced imaging to determine the extent of infiltration. A perirectal abscess can be further divided into a category based on anatomical location...