Anorectal Abscess and Fistula
Anorectal abscess and fistula management is a cornerstone of any colorectal surgeon’s practice. Knowledge of anatomic structures and their relationship to each other is imperative to make the correct diagnosis and define the treatment plan. Many studies h
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Key Concepts • Successful management of anorectal abscesses requires an in-depth knowledge of pelvic floor anatomy and potential spaces through which sepsis can spread. • The spaces occupying the anus and their anatomic landmarks will define the nomenclature of abscesses— perianal, perirectal, supralevator, and postanal space. • Drainage of most abscesses can be performed in the office without drains or setons. If a fistula is encountered it should only be addressed if the anatomy in relationship to the sphincters is clearly identified. • Necrotizing soft tissue infections are life-threatening emergencies that require aggressive surgical debridement and management of the offending anal gland. • Fistulas will complicate a significant proportion of perirectal abscesses and are classified based on their relationship with the anal sphincter complex. • Physical examination is often the only modality needed to determine the fistula track and selection of treatment, and preoperative imaging (MRI, US) is typically unnecessary except for patients with multiple external openings, when the internal opening cannot be identified, or for recurrent cases. • Goodsall’s rule, while being helpful, is accurate in about 60 % of cases and is more accurate for posterior fistulas. • Fistulotomy is the most successful of the surgical treatments, but is also associated with the highest rates of continence disturbances—several non-cutting techniques have been described—all of which have limitations and varying degrees of success.
Introduction and Epidemiology It is difficult if not impossible to accurately assess the incidence of anorectal abscesses because they often drain spontaneously or are incised and drained in a physician’s office, emergency room, or surgicenter. Herand Abcarian [1]
While seemingly a benign process, an anorectal abscess can produce significant distress and long-term morbidity. Delay in diagnosis, mismanagement of the disease, or failure to recognize the diagnoses can result in multiple procedures, increased cost, and protracted suffering. Further, confusion regarding the interplay between anorectal abscesses and fistula-in-ano may lead to inappropriate management. As such, it is important that treating clinicians have a good working knowledge of the diagnosis and management or refer the patient to a specialist. Although the true incidence and prevalence are elusive, data from the operative management of anorectal abscesses provides a floor from which to extrapolate. The incidence of abscess is reportedly between 0.4 and 5 % of patients undergoing operative management [2, 3] translating to 8.6–20 patients per 100,000 population [4, 5], and yielding between 68,000 and 96,000 cases of anorectal abscess each year in the USA [1]. Patients are males at a 3:1 ratio, with both sexes presenting at a mean age of 40 years (range 20–60 years) [6]. Although often asked by patients, there is minimal data to suggest that inadequate hygiene, anal-receptive intercourse, altered bowel habits, diabetes, obesity, or race are associated with increase
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