Incision and Drainage: Perianal Abscess

TEACHING POINTS 1. Patient Preparation a. No specific patient preparation is required. b. Antibiotics are not routinely used except in patients who are immunosuppressed, have diabetes or cellulitis, or have valvular heart disease. Cultures of the fluid in the abscess are not typically performed because they would likely not change the management or outcome. c. Other patient factors to consider include patient tolerability, anticoagulation, and pertinent medical history, including coagulopathies. d. Contraindications to a bedside procedure include sepsis, extensive abscesses, and abscesses difficult to access anatomically, such as those in the supralevator, retrorectal, or deep postanal space. We consider extensive abscesses to be ones that clearly extend beyond 1 quadrant, are horseshoe abscesses, or are circumferential. Imaging may be recommended for further evaluation in these instances and the procedure may be more appropriately performed in the operating room. 2. Patient Position a. Left lateral Sims position or prone jackknife position. 3. Critical Steps a. Patient positioning. b. Ensure complete exposure of the anal margin. c. Prepare the area with betadine solution. d. Administer local anesthesia. e. Make a cruciate or elliptical incision to unroof the abscess. f. Temporary packing for hemostasis. 4. Technical Pearls/Tips a. Cruciate or elliptical incisions are ideal, but a stab incision can be used. Small stab incisions may close too quickly to achieve complete drainage. b. The incision should be made at the dome of the abscess and as close to the anus as possible to shorten the tract in case a fistula forms. c. Because packing prevents continuous drainage and prolongs healing time, it should be avoided. 5. Potential Areas for Injury/Complication a. Fournier's gangrene is a rare but life-threatening complication. Patients experiencing extreme pain, fever, and urinary retention and demonstrating skin blistering, foul smell, and tenderness on examination should be evaluated and treated emergently. b. Persistent drainage and recurrent abscesses may be a sign of fistula formation. VIDEO SUMMARY This video demonstrates a patient with a perianal abscess treated with incision and drainage. The patient is placed in a left lateral Sims position and the anal margin is exposed. The perianal area is prepared using betadine. A cruciate incision is made and pressure is applied around the incision site to facilitate drainage. The abscess is unroofed to expose the base and allow further drainage. Packing is temporarily placed to achieve hemostasis.U1 KEY IMAGE {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_5rwhg0k3"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} See video on the DCR YouTube Channel at https://youtu.be/ZWXjnnJF-CQ