Questionnaire/history:

Risk factors?

- Inflammatory bowel disease

- Smoking and

- HIV infection

(Note: 90% of idiopathic abscesses result from infected crytoglobular glands, abscesses may be superficial (60%) or deep to the anal sphincter)

Increasing perianal pain and tender, erythematous swelling +/- discharge (superficial abscess)?

Vague symptoms of pain and fever before anything is visible, buttock erythema and induration on the affected side will eventually become apparent (ischiorectal abscess)?

Sepsis, especially if IBD (deep abscess, MRI)

Management:

Referral for incision and drainage within 24 hours and avoiding prescribing trials of antibiotics

Resolution is unlikely regardless of antibiotics once a pocket of infection has developed unless it is opened up

Abscesses may cause or be caused by, anal fistula, which affected 1/3 at or after an abscess and will lead to persisting symptoms irrespective of antimicrobial use

Incision and drainage is most appropriately conducted under general anaesthetic which allows for more detailed assessment, including the exclusion of fistulae and any contributing pathology

Data shows that outcomes are the same whether antibiotics are used postoperatively or not

May be recommended in specific patients, such as those with systemic symptoms, extensive cellulitis, or are immunosuppressed and in the presence of certain organisms associated with poorer outcome

Healing:

Post-operatively the wound needs to heal by secondary intention

Takes 3-4 weeks, traditionally achieved by daily packing, which is painful and time -consuming for the patient, and labour intensive for general practices

Resource(s):

BMJ 2017