Perianal abscess

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]

Synonyms and Keywords: Anorectal abscess, Ischiorectal abscess, Supralevator abscess, Horse shoe abscess
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Anorectal abscess is secondary to blockade of the anal gland ducts, resulting in a infection of the gland. The anatomical position of the anal glands in relation to the anal canal is responsible for the variation in the location of the abscess. Initial infection occurs in the anal gland duct and it takes the path of least resistance. The anorectal abscess are classified into low abscess and high based on the location of the abscess. Patients with low abscess present with anal pain associated with bowel movement, and patients with high abscess present systemic manifestations such as fever and malaise in addition to anal pain. On examination tenderness and flactulance suggest anorectal abscess. It is an emergency condition and must be treated promptly within 24 hours of presentation as spread of infection can result in perineal cellulitis and sepsis. Incision and drainage is the definitive treatment and should be performed under local or general anesthesia based on the location of the abscess. With treatment prognosis is good but a risk of recurrence and formation of a fistula is high in patients with improper drainage and failure to identify existing fistula. Antibiotic therapy does not help with treatment of the infection and wound healing.

Historical Perspective


Based on the location of the abscess in relation to the anal canal and the spread of infection to the surrounding structures, anorectal abscess can be classified into [2][3]

  • Perianal abscess: When the infection reaches the anal verge passing between the internal sphincter and external sphincter, it results in the formation of a perianal abscess.
  • Ischiorectal abscess: If the infection ruptures through the external sphincter it results in a formation of a ischiorectal abscess.
  • Supralevator abscess: If the infection extends superiorly, it can form a supralevator abscess.
  • Horseshoe abscess: Extension of the abscess to both the ischiorectal fossa results in the formation of a horseshoe abscess.

Based on the location the abscesses can also be classified into:[4]

  • High anorectal abscess: These include intersphincteric, perianal, and ischiorectal abscesses.
  • Low anorectal abscess: These incude submucosal, supralevator abscesses.



  • Anal canal is a 2 to 4cm in length, starts at the anorectal junction to the end of anal verge.[5]
  • It is divided into a upper and a lower part by transition zone that is seen at the dentate line or pectinate line which is surrounded by longitudinal mucosal folds, called columns of morgagni.[5]
  • Each of this fold contains anal crypts, each of which contains 3 to 12 anal glands, the distribution of these glands is not uniform with most of the glands present anterior to the position of the anal canal and fewer in the posterior position.[5]
  • The initial infection occurs in the ducts of the anal glands and the spread of infection results in the formation of the abscess, various theories were put forward to describe the pathogenesis and the most accepted one is the cryptoglandular theory.[6]
  • The crytoglandular theory states that obstruction of anal gland duct results in a infection and due to the presence of these glands deep in relation to the anal canal and sphincter, the infection follows the path of least resistance resulting in abscess formation at the termination of the gland.[7][8]


Source of Infection

Microbial Causes

Organisms commonly causing anorectal abscess include:

Epidemiology and Demographics



  • Anorectal abscesses are two times more frequently seen in men than women.[10]


  • Patients with anorectal abscess present between ages of 20 to 60 years with a mean age of 40 in both sexes.[1]


Risk Factors

Risk factors for the development of recurrent of anal abscesses include[12]:

Differential Diagnosis

Anorectal abscess must be differentiated from other causes of anal pain including anal fissure, thrombosed hemorrhoids, levator spasm, sexually transmitted disease, proctitis, hidradenitis suppurativa, infected skin furuncles, herpes simplex virus, tuberculosis, syphilis, actinomycosis and cancer.[14]

Disease Definition Causes Clinical Features Diagnosis
Fistula in ano
  • A epithelialized track formed between the anorectum and the perianal skin secondary to rupture of anorectal abscess
  • Chronic manifestation of anorectal abscess
Anal Fissure
  • Clinical diagnosis
Thrombosed External Hemorrhoids
  • Engorged fibrovascular cushions lining the anal canal
  • Constipation
  • Prolonged straining
  • Clinical diagnosis
Levator spasm
  • Seen in patients with perfectionistic, anxious somatic, and/or neurotic tendencies
  • Severe anal pain lasting for seconds to 5 minutes
  • Diagnosis is by Rome IV criteria
  • It is diagnosis of exlusion
Hidradenitis suppurativa
  • Causes unidentified
Infected skin furuncle
  • Well-circumscribed, painful, suppurative inflammatory nodule involving hair follicles
  • Clinical diagnosis
Bartholin's abscess

Perianal absscess must be differentiated from other diseases that cause anal discomfort and pain with defecation such as hemorrhoids, anal fissure and anal cancer.

Disease History Physical exam findings Sample image

External hemorrhoids

  • External hemorrhoids are painful as the skin below the punctate line is sensitive to pain.[1]
  • Blood clots may form in external hemorrhoids.
  • Thrombosed external hemorrhoids cause bleeding, painful swelling, or a hard lump around the anus.
  • When the blood clot dissolves, extra skin is left behind. This skin can become irritated or itch.
  • Excessive straining, rubbing, or cleaning around the anus may make symptoms, such as itching and irritation, worse.

Internal hemorrhoids

  • The most common symptom of internal hemorrhoids is bright red blood on stool, on toilet paper, or in the toilet bowl after a bowel movement.
  • Internal hemorrhoids that are not prolapsed are usually not painful.
  • Prolapsed hemorrhoids often cause pain, discomfort, and anal itching

Skin examination

  • Inspection of the anal verge may show scratch marks and skin tags.
  • Inspection also may reveal external hemorrhoids or prolapsed internal hemorrhoids.

Digital rectal examination

External hemorrhoids - By Dr. Joachim Guntau -, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=18660115
Anal fissure
  • Anal fissure usually presents with tearing pain with every bowel movement.[15]
  • Pain usually lasts for minutes to hours after every bowel movement.
  • Patient is typically afraid of going to the bathroom to avoid the pain, which leads to a viscious cycle. The fissure worsens the constipation and the constipation (hard stool) aggravates the fissure.
  • About two-thirds of the patients present with bright red blood streaks on toilet papers or on the surface of stools.
  • May be accompanied by pruritis and discharge.
Anal fissure - Own work, Public Domain, httpscommons.wikimedia.orgwindex.phpcurid=8885750
Rectal prolapse
  • Rectal prolapse most commonly occurs in multiparous females over 40 years old.[17]
  • Appears as a progressive mass protrusion from the anus. The protrusion first appears with straining and defecation, then progresses to the degree when it is no longer replaced back.
  • It presents with abdominal discomfort and incomplete defecation.
  • Fecal incontinence and anal discharge.
  • Pain is not usually present.
Rectal prolapse - By Dr. K.-H. Günther, Klinikum Main Spessart, Lohr am Main - Dr. K.-H. Günther, Klinikum Main Spessart, Lohr am Main, CC BY 3.0, httpscommons.wikimedia.orgwindex.phpcurid=20649968
Perianal abscess
  • Perianal abscess presents with severe, continuous, dull, aching pain in the perianal area.[19]
  • Pain is exacerbated with bowel movements, but is not exclusive to it.
  • Constipation due to fear of bowel movements.
  • Fever, headache, and chills may accompany the pain.
  • If the abscess starts to drain, discharge of purulent or bloody fluid may be noticed.
  • Flatulent, erythematous, and tender area of skin overlying the abscess.
  • If abscess is deep, tenderness is elicited with digital rectal examination.
Anal cancer
  • Rectal bleeding is the most common presentation.[20]
  • Mass sensation in the anus.
  • Mucoid discharge may occur.
  • Patient may give a history of anal condyloma (especially homosexual men).[21]
  • Fecal incontinence.
  • On digital rectal examination, solid hemorrhagic mass that is firmly fixed to the surrounding structures is noted.
  • Femoral and inguinal lymph nodes may show lymphadenopathy secondary to spread of cancer.
Anal Cancer - By Internet Archive Book Images - book page httpsarchive.orgstreamdiseasesofrectum00gantdiseasesofrectum00gant-pagen653mode1up, No restrictions, httpsc
Condylomata acuminata
  • Patient may give a history of unprotected anal sex with an infected partner.
  • Having multiple sexual partners is a risk factor and should be investigated.[22]
  • Condyloma acuminata presents with painless warts that vary in size, shape, and color.
  • Pruritis and discharge may accompany the warts.
  • Anal condyloma acuminata may be accompanied by cervical, vaginal, or even ororpharyngeal warts, so the patient should be examined thoroughly.[23]

Natural History, Prognosis, Complications

Natural History

If left untreated, anorectal abscess can spread to the surrounding tissue and can cause perineal cellulitis and sepsis. Perianal abscess is the most common type followed by ischiorectal abscess.[11]


Prognosis of patients is good with incision and drainage and most patients do not require any antibiotic therapy after the procedure, except for patients with HIV infection, Crohn's disease. Majority of patients have relief of pain after abscess drainage and healing takes time as it heals by secondary intention.[24]



History and Symptoms

Physical Examination

General Appearance

Digital Rectal Examination

Physical examination findings demonstrated in anorectal abscess include: [3]

(Images courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)

Laboratory Findings



  • Endoanal ultrasound is useful in detecting horse-shoe abscesses extension and presence of fistula tracts with high sensitivity.[28]
  • Three dimensional ultrasound is useful in patients to identify the anatomical locations of complex perianal abscesses and fistula tracts.[29]

CT Scan


Medical Therapy

Surgical Therapy

  • Management of anal abscess should be prompt as the risk of involving the surrounding tissue resulting in perineal cellulitis and sepsis is high.[33]
  • Primary treatment for anorectal abscess is incision and drainage and it should be performed within 24 hours of presentation.
  • Patients with perianal abscess and ischiorectal abscess can be treated in a outpatient setting under local anesthesia using 1% lidocaine or bupivacaine with epinephrine is injected subcutaneously into the area affected by the abscess to provide adequate infilteration into the skin. [3]
  • Patients with loculations or large ischiorectal, intersphincteric, supralevator, or horseshoe abscesses should be admitted to the hospital and the procedure should be performed under anesthesia.[3]




Primary Prevention

Secondary Prevention


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