Anorectal abscess

Last reviewed: 22 Aug 2023

Last updated: 21 Dec 2022

Anorectal abscess commonly presents with perianal pain with leukocytosis.

Usually treated by incision and drainage.

Adjunctive antibiotics are unnecessary for uncomplicated cases. Antibiotics are indicated for patients with associated cellulitis, immunocompromise, signs of systemic infection, diabetes, or a history of cardiac valvular disease.

Definition

An anorectal abscess is an infection of the soft tissues around the anus.[1] Severe perianal pain and swelling are the most common presenting complaints. Other symptoms include fever, chills, or urinary retention.[2] Rarely, patients may present with life-threatening sepsis from an associated necrotizing soft-tissue infection.[3] The diagnosis of an anorectal abscess can usually be made by physical examination, but occasionally atypical or occult abscesses require a computed tomography scan, ultrasound, or magnetic resonance imaging.[4][5][6]

History and exam

Key diagnostic factors

anal fistula
history of Crohn disease
male sex
perianal pain
perianal or rectal induration

More key diagnostic factors

Other diagnostic factors

perianal swelling
low-grade fever
tachycardia
change in bowel habits
rectal bleeding
inability to urinate

Other diagnostic factors

Risk factors

anal fistula
Crohn disease
male sex
hard stools
age 21 to 40 years

More risk factors

Diagnostic investigations

1st investigations to order

clinical examination
examination under anesthetic

More 1st investigations to order

Investigations to consider

WBC count
serum glucose
serum electrolytes
anal ultrasonography
CT pelvis
MRI pelvis
microscopic examination and/or culture of the purulent fluid

More investigations to consider

Treatment algorithm

ACUTE

all patients

Contributors

Authors

Jan Rakinic, MD, FACS, FASCRS

Professor of Surgery

Chief

Section of Colorectal Surgery

Southern Illinois University School of Medicine

Springfield

Disclosures

JR is an author of a reference cited in this topic.

Acknowledgements

Dr Jan Rakinic would like to gratefully acknowledge Dr C. Neal Ellis, a previous contributor to this topic.

Disclosures

CNE declares that he has no competing interests.

Peer reviewers

Mark H. Whiteford, MD

Assistant Professor of Surgery

Colon and Rectal Surgery

Gastrointestinal and Minimally Invasive Surgery Division

The Oregon Clinic

Portland

Disclosures

MHW declares that he has no competing interests.

Neil Hyman, MD

Chief

Division of General Surgery

Professor of Surgery

Fletcher Allen Healthcare

Burlington

Disclosures

NH declares that he has no competing interests.

Steven Brown, MBChB, FRCS, MD, BMedSci

Consultant Surgeon

Department of Colorectal Surgery

Sheffield Teaching Hospitals

Sheffield

Disclosures

SB declares that he has no competing interests.

Differentials
- Anal fissure
- Thrombosed hemorrhoid
- Pilonidal abscess
More Differentials
Guidelines
- The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula
- ACR appropriateness criteria: anorectal disease
More Guidelines
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Anorectal abscess

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

all patients

Contributors

Authors

Jan Rakinic, MD, FACS, FASCRS

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Mark H. Whiteford, MD

Disclosures

Neil Hyman, MD

Disclosures

Steven Brown, MBChB, FRCS, MD, BMedSci

Disclosures

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

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