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11.13 Ischiorectal Abscess
151
then take it towards the infected crypt and open
the tract. Probing from the outside may lead to an
iatrogenic opening due to inammation [21].
11.13 Ischiorectal Abscess
An ischiorectal abscess is a large, edematous,
indurated, or tender mass in the gluteal region.
The incidence reported is 20–25%. Pus is always
present, and one should never wait for the abscess
to mature [22]. Needle aspiration can help in the
diagnosis [22]. Sometimes, it may be associated
with systemic ndings. The patient may complain of severe pain. Fluctuation is a delayed
nding if the abscess is deep-seated, and a
brawny induration may be visible. Proctoscopy
causes discomfort to the patient. The pus may be
seen exudating from the crypt on pressing the
swelling. Perforation of large rectal cancer might
result in a large ischiorectal abscess [22].
Infection from the ischiorectal space can
invade Milligan’s septum to reach the perianal
space. On the other hand, infection from the perianal area seldom spreads to the ischiorectal space
[23]. The infection may spread to the opposite
ischiorectal region, forming a horseshoe abscess
due to the continuation of the puborectalis sling
behind the anorectal junction [23]. An abscess in
the postanal space can also lead to bilateral
ischiorectal abscess due to communication of the
deep postanal spaces with bilateral ischiorectal
fossae.
Imaging the affected area is benecial in cases
where the patient cannot tolerate digital rectal
examination.
11.13.1 Managing Ischiorectal Abscess
Drain the abscess under general or spinal anesthesia by giving an incision near the anal margin to
ensure that the subsequent stula formation is
small. Give a small radial incision on the most
medial aspect of the abscess. Evacuate the pus,
and rinse the abscess cavity with normal saline.
Place a loose gauze wick to keep the opening patent for drainage of pus. A drain can be placed for
24–48h to ensure adequate drainage. Some surgeons try to break the loculi with ngers, which is
not advisable. It is not the loculi one is breaking,
but the bers of the inferior rectal nerve branches
present there. The breaking of nerve bers may
lead to paranesthesia in the ischiorectal area.
11.13.2 How toIdentify
Communicating Fistula
Tract?
The pus is aspirated from the most medial aspect
of the abscess as near the anal verge as possible.
Inject methylene blue and hydrogen peroxide to
see if the dye is coming through an internal opening on the dentate line. If bubbles are present, one
should go for a primary stulotomy after assessing the extent of sphincters involved. If one fails
to detect the internal opening or is unsure about
the extent of the external sphincter involved,
it is preferred to drain the abscess alone
(Fig. 11.7a–h). One can insert a loose draining
seton if unsure about the extent of the external
sphincter involved.
152
11 Evaluation andManagement ofAnorectal Abscess
a
b
Fig. 11.7
(a–h) Diagrammatic representation of the
management of ischiorectal abscess. (a) Ischiorectal
abscess with communicating trans-sphincteric stula
tract. (b) Injecting methylene blue and H
into the
2O2
abscess cavity after withdrawing pus. The bubbles at the
internal opening indicate a communicating transsphincteric stula tract. (c) Drainage of abscess from the
most medial part of the swelling by giving radial incision
followed by probing from internal opening toward the
radial incision. (d) Primary stulotomy to be carried out
only if the anatomy of the sphincters is evident. (e)
Fistulotomy with marsupialization and excision of internal opening including mucosa, submucosa, and surrounding tissue to eradicate infection. (f) Seton placement after
drainage of the ischiorectal abscess with communicating
tract when the anatomy of the sphincters is not precise. (g)
Drainage of pus from the most medial part of the abscess
with a radial incision when no communication exists with
the anal canal. (h) Empty abscess cavity after drainage of
pus which collapses over time
11.13 Ischiorectal Abscess
c
d
153
Fig. 11.7 (continued)
154
11 Evaluation andManagement ofAnorectal Abscess
Fig. 11.7 (continued)
11.13 Ischiorectal Abscess
155
Fig. 11.7 (continued)
156
11 Evaluation andManagement ofAnorectal Abscess
11.14 Intersphincteric Abscess
The intersphincteric abscess is formed in the
intersphincteric space. Some authors describe
it as an intermuscular abscess, as it lies in the
longitudinal conjoined muscle and the internal
anal sphincter. Eisenhammer had described
and divided the abscess into low and high types
[24, 25]. The low type is present only in the
intersphincteric space, whereas the high pres-
Fig. 11.8 (a)
Intersphincteric abscess.
(b) Intersphincteric
abscess with extension
to supralevator
a
ents as an extension toward levators or circular
muscle of the rectum (Fig.11.8a, b). It is mistakenly called a “submucosal abscess” [7, 9].
The abscess develops from the infected crypt
in the anal canal. The infection is usually present as a swelling within the lower part of the
rectum.
The infection due to an infected anal ssure
may enter from the lowermost portion of the
internal anal sphincter and form an abscess.
b
11.14 Intersphincteric Abscess
157
The clinical presentation is rectal or anal discomfort, which increases on defecation and is
associated with the feeling of fullness in the rectum. The patient may or may not be febrile.
Digital rectal examination reveals a tender submucosal mass with induration and edema.
Anorectal tenderness and bogginess are the most
important ndings. One should differentiate the
condition from thrombosed internal hemorrhoids
as the latter appears as a deep purple hemorrhoidal tissue mass.
11.14.1 Dierential Diagnosis
Thrombosed internal hemorrhoids.
11.14.2 Managing Intersphincteric Abscess
Under spinal anesthesia, place the patient in a
lithotomy position. Insert a half-cut proctoscope.
Through the transanal approach, widen the internal opening on the dentate line to explore the
intersphincteric plane. Drain the abscess, and
curette and irrigate the intersphincteric space. A
stulotomy is done up to the anal verge to avoid
collection in the intersphincteric space
(Fig. 11.9a). Alternatively, the intersphincteric
space can also be opened up to the anorectal ring
(Fig. 11.9b, c). In the case of a small, localized
collection, the abscess can be excised entirely in
toto. Treat the intersphincteric abscess limited to
Fig. 11.9 (a–c) Managing intersphincteric abscess: (a)
Transanal opening of intersphincteric space after widening the internal opening. Open the intersphincteric space,
as shown in the diagram. Drain the abscess, and excise the
internal opening along with mucosa, submucosa, and sur-
rounding tissue, followed by stulotomy. (b) Insertion of
the probe through the internal opening into the intersphincteric space. (c) Opening of intersphincteric space
with drainage of pus followed by marsupialization of the
margins with anal lining
158
11 Evaluation andManagement ofAnorectal Abscess
Fig. 11.9 (continued)
11.15 Supralevator Abscess
159
the anal canal using a stab incision. Marsupialize
the stulotomy margins. For appropriate drainage, the wound is kept open.
11.15 Supralevator Abscess
A supralevator abscess can arise from three
sources (Fig.11.10a–c):
• Upwards extension of an intersphincteric abscess
• Downward extension from pelvic disease
• Upwards extension of an ischiorectal abscess
The supralevator abscesses are sporadic, comprising 3.6% of anorectal abscesses [26]. The most
common presenting complaint of the patient with
supralevator abscess is perianal and gluteal pain.
The patient may have fever with leucocytosis.
A boggy mass is palpated within the rectum
on examination of an abscess present above the
levators. Palpation may reveal rectal fullness.
Due to its anatomical relation, it is not easy to
diagnose this abscess. Therefore, imaging is a
mandatory investigation.
11.15.1 Managing Supralevator Abscess
Proper evaluation of the tract is essential before
draining the abscess.
• Always look for an internal opening if the
supralevator collection is from an upward
extension of an intersphincteric abscess [9].
Through a transanal approach, widen the
internal opening to enter the intersphincteric
space to drain the abscess. Carry out a stulotomy from an internal opening to the anal
verge for drainage purposes (Fig. 11.11a).
Extend the stulotomy incision in the intersphincteric tract and lay open the intersphincteric space [9]. Place a drain in the supralevator
abscess cavity for irrigation. After curetting
and irrigation of the intersphincteric tract,
some surgeons prefer to ablate the unhealthy
granulation tissue using a laser. Opening the
intersphincteric stula tract is a better
approach.
• If the collection is secondary to abdominopel-
vic disease, drain by CT-guided transrectal
Fig. 11.10 (a–c)
Diagrammatic
representation of
supralevator abscesses.
(a) Upward extension of
an intersphincteric
abscess to supralevator
space. (b) Downward
extension of pelvic
infection leads to
supralevator abscess
formation. (c) Extension
of an ischiorectal
abscess to supralevator
space with
communicating
trans-sphincteric stula
160
11 Evaluation andManagement ofAnorectal Abscess
Fig. 11.10 (continued)