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)\

 

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 – 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

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– 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

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