ISCHIORECTAL ABSCESS

MARION C. PRUITT, M.D., F.R.c.s., P.A.C.S.

Associate in Surgery (Proctology), Emory University SchooI of Medicine

ATLANTA, GEORGIA

A
CUTE abscess in the anorecta1 region posterior ana fissure. They aIso may be
is usually due to infection by the caused by stranguIated, gangrenous, in-
common pyogenic organisms foIIow- fected hemorrhoids. OccasionaIIy abscess
ing irritation, traumatism, inffammation, may foIIow anorecta1 operations due to
or uIceration in the ana cana1. It has its spread of infection into deeper tissues but
point of origin most often at the pectinate most often postoperative infection gives
Iine in one of the ana crypts. In reIation rise to a subcutaneous type of abscess.
to the anus and rectum, abscess occurs in In addition to the above causes infection
various anatomic Iocations, thus : and uIceration may originate in the ana
I. If the infection extends upwards in crypts and terminate in ischiorecta1 ab-
the recta1 waI1 the abscess origi- scess. TubercIe baciIIus, gonococcus, and
nates in the submucosa. This Ioca- Vincent’s organisms may be considered
tion is rare. as causes.
2. UsuaIIy the abscess is outside the gut AIso an infection of an abrasion of the
waI1 in one of three positions: skin or acute inffammation of periana1 skin
(a) Above the pelvic diaphragm in without abrasion or uIceration may
the superior perirectal space. through the Iymphatics terminate in an
(b) Subcutaneous around the anus. ischiorecta1 abscess. Infection may occur
(c) In the ischiorectal fossa. by direct extension from retrorecta1 or
Of the above Iocations the most fre- superior peIvirecta1 spaces, or from uro-
quent position of abscess in the anorecta1 genital organs.
region is in the ischiorecta1 fossa.
SPREAD
CAUSE OF ISCHIORECTAL ABSCESS

Besides chemical irritation and trauma-
tism caused by the passage of bowe1 con-
tents to the Iower part of the rectum and
anus, ischiorecta1 abscess may foIIow in-
jury by the passage of foreign bodies, such
as seeds, fragments of bones, toothpicks,
or pins. These foreign bodies may become
Iodged in the ana cana due to the abrupt
narrowing of the bowe1 at this point and
the direction upwards of the ana crypts.
When infection gains a foothoId in such
an injured area it tends to spread aIong
the Iymphatics or through the gut waI1
at the point where the Ievator ani and
IongitudinaI muscuIar coat of the bowe1
pass between the sphincters, and in this
way may reach the ischiorecta1 fossa.
Many ischiorecta1 abscesses resuIt from
the spread of infection from a negIected
When an abscess originates in the ischio-
recta1 fossa it spreads through the Ioose
adipose tissue without causing any obvious
sweIIing unti1 considerabIe tension is pres-
ent. As it continues to deveIop it is Iimited
IateraIIy by the obturator fascia which
covers the obturator muscIe, and above and
behind by the Ievator fascia which covers
the Iower surface of the Ievator ani muscle.
The Ievator ani practicaIIy surrounds the
rectum posteriorIy in such a way as to form
a space at the back of the anorecta1 junc-
tion through which the ischiorecta1 fossa
may communicate with the one on the
other side.
As the tension in the abscess increases
it tends to burrow in the Iine of Ieast
resistance : it may trave1 downward to
open on the skin surface, or aIong the anal
670 A unerican Journd of Surgery Pruitt-IschiorectaI Abscess DE<

porti :on of the Ievator fascia, which is posterior fissure or infection of an ana
direc :tIy attached to the muscuIar coats crypt. A peIvirecta1 abscess may rupture
of th le a na1 cana between the two sphinc- into the ischiorecta1 fossa and in this way

FIG. I. Photograph and drawing of a large acute ischiorecta1 abscess.

ters, to open into the ana cana at the cause a peIvirecto-ischiorecta1 abscess. It
anorecta1 junction. However the infection is rare for an ischiorecta1 abscess to extend
may spread directIy through the posterior upwards into the peIvirecta1 space. In
passageway between the sphincters behind some cases it may extend between the
the rectum to the opposite side. sphincters upwards and form a submucous
Infection in the ana cana1, especiaIIy abscess.
aIong the pectinate Iine posteriorIy, may The ischiorecta1 fossa is pyramida in
pass through the Iymphatics to either shape and is situated on each side of the
fossa or to both, though the infection usu- anus and Iower part of rectum externa1
aIIy deveIops more rapidIy on one side to the sphincter muscIes. Under extreme
than the other. When both sides are in- tension it may distend to hoId 4 to 8
voIved it is known as a “dumbbeI1” ounces of pus. When more than this is
abscess : such an abscess tends to terminate evacuated one must suspect that an ab-
in a “horseshoe” fistuIa with the interna scess in the superior peIvirecta1 space has
opening Iocated at the posterior midIine perforated through the Ievator ani, forming
in the ana crypt. This indicates that the a secondary ischiorecta1 abscess. The com-
origin of the infection which terminates bined Iocations makes a condition very
in an ischiorecta1 abscess was probabIy a compIicated and diffxcuIt to treat.
NEW SERIES VOL. XLVI, No. 3 Pruitt-IschiorectaI Abscess American Journal of Surgery 671

The possibihty of tuberculous abscess in At first there are no apparent Iocal signs
the ischiorecta1 fossa wiI1 not be discussed but soon induration may be feIt aIong the
in this paper as it is rare: such abscesses side of the anus, folIowed by increase of

FIG. 2. A stab wound has been made in the ischiorectal abscess shown in Figure I. The
pressure within is illustrated by the force of the stream of pus spurting out of the
abscess cavity through the stab wound photographed at the time of the incision. The
dotted Iine indicates enIargement of the stab wound to permit evacuation of the pus
and exploration of the extent of the cavity.

usuaIIy resuIt as a secondary extension IocaI temperature, redness and discolora-

from above in the tubercuIous patient.
SYMPTOMS
IschiorectaI abscess deveIops as an acute
IocaI inff ammatory condition. The patient
compIains of chiIIy sensation, headache,
fever, and at first IocaI discomfort. As the
abscess deveIops and tension increases the
discomfort becomes a constant duII aching
and a feeIing of pressure which is not
reIieved by enema or defecation. Later this
aching deveIops into an intense throbbing
pain.
tion, the degree of which depends on the
depth of the infection. When the abscess
begins high in the ischiorecta1 fossa it may
be necessary to introduce the finger in the
ana cana and press outward to determine
earIy induration and sweIIing. When the
abscess has existed two, four, or more days
a tense inffamed sweIIing which may or
may not ffuctuate is present at the side
of the anus externa1 to the sphincter
muscIes. If aIIowed to continue, it wiI1
open spontaneousIy as a ruIe on the skin
surface or in the rectum at the anorecta1
junction.
672 American Journal of Surgery Pruitt-IschiorectaI Abscess DECEMBER, 19x1

TREATMENT the patient more comfortable. However, to

From the etioIogic factors invoIved one temporize with such measures in hope that
may appreciate the importance of preven- the abscess wiI1 subside is useIess. To wait

FIG. 3. The dotted Iine in the photograph and the solid Iine in the drawing Zlustrate the
racket-shaped incision empIoyed to unroof the abscess cavity.

tive measures. These incIude avoidance of for the abscess to open spontaneousIy
both constipation and of drastic purga- proIongs the patient’s suffering and as the
tives, the avoidance of injury from enema size of the abscess increases, it means
tips, and care not to swaIIow seeds or heaIing wiI1 be proIonged and a f%tuIa wiI1
other foreign bodies. It also is important aImost certainIy foIIow.
to cIear up IocaI pathoIogy. In cases where the induration and
When an ischiorecta1 abscess has de- tumefaction are such as to bring up the
veIoped, onIy one method of treatment question of gas gangrene infection, it seems
shouId be considered: nameIy, opening wiser to administer suIfaniIamide in Iarge
and draining the abscess at once. As soon doses and wait. Often suIfaniIamide gives
as the tension is reIieved the abscess reIief of symptoms and causes the acute
ceases to spread and an earIy incision may infection to subside. Then foIIows genera1
prevent subsequent fistuIa. LittIe if any improvement of the patient. CertainIy
resuIt shouId be expected from the com- this method of treatment is advisabIe unti1
mon use of recta1 suppositories. If for the question of gas gangrene is cIeared up,
some reason operation cannot be done as incision into such infection before pus
immediateIy, hot fomentations and hot formation is of doubtfu1 vaIue and may
sitz baths tend to reIieve pain and make spread the infection.
NEW SERIES VOL. XLVI, No. 3 Pruitt-Ischiorectal
Anesthesia. Genera1 and Iow spina are
the idea1 methods of anesthesia.
LocaI i&Itration of nupercaine (I : r ,000)
or procaine (I per cent), etc. superficiaIIy
over the area to be incised, are commonly
used, but this anesthesia may be incom-
pIete and at times Iimits the operation.
Never use ethy1 chIoride spray, as the
anesthesia is incompIete, the extent
area Iimited, and the discomfort from the
anesthetic agent is usually greater than the
anesthetic effect.
Operation. The location and type of
incision to be made depends on the extent
of abscess at the time of opening. As a ruIe
the incision should be made Iateral to the
external sphincter muscIe into the most
prominent area of sweIIing or induration.
Incision into indurated area even before
pus is formed may at times be advisabIe to
relieve tension. It may prevent further
spread of the abscess. The incision shouId
be sufficient in Iength to give free drainage.
To make a small stab incision into an
abscess cavity and then pIug it with gauze
prevents drainage and can only cause pain
to the patient. After drainage is estab-
lished with a good free incision there is no
advantage in irrigation or breaking up of
the abscess cavity. Hot sitz baths not only
make the patient more comfortabIe, but
help to cIeanse the parts and keep up
drainage.
When the abscess is Iarge and there is
marked sweIIing of periana1 tissue, an
anteroposterior incision is made over the
most prominent portion of the swehing
across the entire width of abscess (Fig. 2);
this incision should be made Iateral to the
sphincter. The finger is now gentIy intro-
duced into the wound and the extent of
the abscess cavity determined. Then with
scissors or knife the roof of the cavity is
cut away and the incision is continued into
the anus, sparing the sphincter muscle,
Abscess American Journal of Surgery 673
Ieaving a racket-shaped opening. (Fig. 3.)
This racket-shaoed incision is made so
that if a fistuIa shouId deveIop the externa1
opening would be in the handIe of the
racket near the anal margin and not far
out on the buttocks as in a -r-shaped
incision where the IateraI incision extends
outwards. The reasons for the incision are:
of to remove the skin waI1 over the abscess
cavity; to decrease the depth of the cavity;
to bring the Iast part of the abscess cavity
to hea near the ana margin; and to place
the handle of the racket as far back towards
the posterior anal margin as possible. It
may be necessary to cut away much of the
cutaneous structures. Packing should be
avoided other than for contro1 of hemor-
rhage. The patient is put to bed and in
about two days hot sitz baths are begun.
It is hardly believable how rapidIy the
cavity of the abscess may be covered over
with new skin. The cutaneous structures
shouId be kept open unti1 the abscess
cavity can heal from the bottom. The pa-
tient should be told that a fistula may
follow and a Iater operation for this may
be necessary for a cure.
As a supportive postoperative treatment
su1faniIamide in Iarge doses often aids
much in clearing up the infection, promot-
ing rapid heaIing, and preventing a hstula.
For some time this has been included in
my postoperative routine.
To open an ischiorecta1 abscess in the
acute stage and then proceed to do a
radica1 operation for a fistula (cutting the
sphincter muscIes) may often leave a large
open wound, marked retraction of sphinc-
ter muscle, folIowed by much scar tissue
and deep sulcus in the anus and often
partial or compIete incontinence. Drainage
of the abscess cavity as described above is
all that shouId be undertaken in the acute
case.