Anorectal Abscess Approach

– History –

  • CC: most likely will present as perianal pain\abscess:
    • Site: where? Does it radiate anywhere else?
    • Onset: first time? When? Sudden\gradual? Intermittent\continuous? Better\worse?
    • Character: dull, throbbing, stabbing?
    • Aggravating\relieving: worse w\ defecation? Movement? Prolonged sitting?
    • Severity: 1-10 scale? Wakes you up from sleep? Interfering w\ ADL?
  • Associated sx:
    • Constitutional: fever, chills, wt loss, decreased appetite?
    • Perianal: swelling, itching, discharge (pus), bleeding (if yes, did you notice it on the toilet paper, underwear, mixed w\ stool, fresh\bright\dark, streak\spotting)?
    • Stool: change in bowel habit (esp constipation), blood in stool?
    • Urine: dysuria, blood in urine, straining?
  • PMHx:
    • Diseases:
      • Chronic ds (HTN, DM, DLP)
      • IBD
      • Infections
    • Medications
    • Surgery, hospitalization, trauma
    • Blood transfusions, IV drug use, tattoos
    • Allergies
  • FMHx:
    • Similar complaint?
    • Same diseases as in PMHx?
  • Social Hx:
    • Occupation, marital status, children
    • Smoking, alcohol, recreational drugs
    • Travel Hx
    • Diet, exercise (weight lifting)\

 


 – Anorectal Physical Exam –

  • WIPE, blah blah 🙂
  • “Take vital signs”
  • Position: Left lateral position, hips + knees flexed
  • Proper exposure: from the waist to the knees
  • Tell the pt it will be uncomfortable but not painful, and ask them to relax and take a deep breath

1. Inspection: (lift the uppermost buttock with your left hand)

  • Skin: rashes, excoriation
  • Scars, sinuses, fistulae openings
  • Ulcers, fissures, skin tags
  • Warts
  • External hemorrhoids
  • Abscesses:
  • Fecal soiling, blood, mucus
  • If you see and abscess, desribe it:
    • By inspection:
      • Site?
      • Overlying skin: red, cellulitis, necrotizing fasciitis?
      • Discharge?
      • Sinus, fistula, punctum?
    • By external palpation:
      • Hot
      • Tender
      • Ill-defined
      • Indurated
      • Fluctuant
      • Bulge on PR exam

2. PR exam: (ask the pt if they have any pain?)

  • Lubricate your finger
  • Insert your finger and rotate 360°
  • Assess sphincter tone:
    • Ask pt to squeeze your finger
  • Comment on:
    • Irregular texture of the rectal wall?
    • Masses?
    • Stool in the rectum?
  • Extra, depends on gender:
    • If male -> palpate prostate;
      • Normal prostate: “firm, rubbery, bi-lobed, symmetrical, 2-3 cm across, smooth surface, shallow central sulcus”
    • If female -> do bimanual exam
  • Withdraw your finger + check glove for: blood, stool, mucous

3. To complete: examine inguinal LN

Anorectal abscess apprroach 1


– Investigations –

  • Usually no labs are needed, unless immunocompromised (DM, HIV) -> blood work (shows leukocytosis)
  • Imaging might help if high clinical suspicion but not obviously apparent: CT, US, MRI

– Management –

  • Incision and drainage
  • Simple perianal abscess can be drain in ED, complex perirectal abscess can be drained in OR
  • Abx are not indicated, unless SIRS\sepsis, cellulitis, DM, immunocompromised

– Complications –

  • Fistula
  • Bacteremia and sepsis
  • Fecal incontinence

Anorectal abscess apprroach 2Anorectal abscess apprroach 3

 


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