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| ==Overview==
| | {{Roseola}} |
| ==Historical Perspective==
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| *In 1880, Herman and Desfosses described the anal glands within the internal sphincter, sub-mucosa and their opening into the anal crypts and demonstrated that the infection of these glands and the spread of the infection through the intersphincteric space can result in the formation of a anal abscess.<ref name="pmid22379401">{{cite journal| author=Abcarian H| title=Anorectal infection: abscess-fistula. | journal=Clin Colon Rectal Surg | year= 2011 | volume= 24 | issue= 1 | pages= 14-21 | pmid=22379401 | doi=10.1055/s-0031-1272819 | pmc=3140329 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22379401 }} </ref>
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| *Tucker and Hellwig, provided evidence that the initial infection occurs in the anal ducts allowing the infection to spread from the anal lumen into the anal canal wall.<ref name="pmid22379401">{{cite journal| author=Abcarian H| title=Anorectal infection: abscess-fistula. | journal=Clin Colon Rectal Surg | year= 2011 | volume= 24 | issue= 1 | pages= 14-21 | pmid=22379401 | doi=10.1055/s-0031-1272819 | pmc=3140329 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22379401 }} </ref>
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| *In 1950, Goligher described the treatment for anal abscess with inicision and curettage with antibiotic bath and primary closure.<ref name="pmid22379401">{{cite journal| author=Abcarian H| title=Anorectal infection: abscess-fistula. | journal=Clin Colon Rectal Surg | year= 2011 | volume= 24 | issue= 1 | pages= 14-21 | pmid=22379401 | doi=10.1055/s-0031-1272819 | pmc=3140329 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22379401 }} </ref>
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| ==Classification==
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| Based on the location of the abscess in relation to the anal canal and the spread of infection to the surrounding structures, anal abscess can be classified into <ref>{{cite journal |author=Janicke DM, Pundt MR |title=Anorectal disorders |journal=Emerg. Med. Clin. North Am. |volume=14 |issue=4 |pages=757–88 |year=1996 |month=November |pmid=8921768 |doi= 10.1016/S0733-8627(05)70278-9|url=}}</ref>
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| *'''Perianal abscess:'''When the infection reaches the anal verge passing between the internal and external sphincter, it results in the formation of a perianal abscess.
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| *'''Ischiorectal abscess:'''If the infection ruptures through the external sphincter it results in a formation of a ischiorectal abscess.
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| *'''Supralevator abscess:'''If the infection extends superiorly, it can form a supralevator abscess.
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| *'''Horseshoe abscess:'''Extension of the anal abscess to both the ischiorectal fossa results in the formation of a horseshoe abscess.
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| Based on the location the abscesses can also be classified into:
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| *'''High anorectal abscess:''' These include intersphincteric, perianal, and ischiorectal abscesses.
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| *'''Low anorectal abscess:''' These incude submucosal, supralevator abscesses.
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| ==Pathophysiology== | | ==[[Roseola overview|Overview]]== |
| ===Pathogenesis===
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| *[[Anal canal]] is a 2 to 4cm in length, starts at the anorectal junction to the end of [[anal verge]].<ref name="urlAnatomy and Embryology - Springer">{{cite web |url=http://link.springer.com/chapter/10.1007%2F978-1-4419-1584-9_1 |title=Anatomy and Embryology - Springer |format= |work= |accessdate=}}</ref>
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| *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]].<ref name="urlAnatomy and Embryology - Springer">{{cite web |url=http://link.springer.com/chapter/10.1007%2F978-1-4419-1584-9_1 |title=Anatomy and Embryology - Springer |format= |work= |accessdate=}}</ref>
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| *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.<ref name="urlAnatomy and Embryology - Springer">{{cite web |url=http://link.springer.com/chapter/10.1007%2F978-1-4419-1584-9_1 |title=Anatomy and Embryology - Springer |format= |work= |accessdate=}}</ref>
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| *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.<ref name="pmid15740520">{{cite journal| author=Rickard MJ| title=Anal abscesses and fistulas. | journal=ANZ J Surg | year= 2005 | volume= 75 | issue= 1-2 | pages= 64-72 | pmid=15740520 | doi=10.1111/j.1445-2197.2005.03280.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15740520 }} </ref>
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| *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 a abscess formation at the termination of the gland.<ref name="pmid13732880">{{cite journal| author=PARKS AG| title=Pathogenesis and treatment of fistuila-in-ano. | journal=Br Med J | year= 1961 | volume= 1 | issue= 5224 | pages= 463-9 | pmid=13732880 | doi= | pmc=1953161 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=13732880 }} </ref>
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| ==Causes== | | ==[[Roseola historical perspective|Historical Perspective]]== |
| ===Source of Infection===
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| *Supralevator abscess can be caused by the spread of infection from [[abdominal infections]] such as [[appendicitis]], [[diverticulitis]], or gynecologic sepsis.
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| *Spread of infection of ano-rectal [[Crohn's disease]].
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| *[[Trauma]] to the [[anal canal]]
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| *[[Cancer]] of the [[anal canal]] or the anal glands
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| ===Microbial Causes=== | | ==[[Roseola classification|Classification]]== |
| Organisms commonly causing anorectal abscess include:
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| *[[E.coli]]
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| *[[Staphylococcus aureus]]
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| *[[MRSA]]
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| ==Epidemiology and Demographics== | | ==[[Roseola pathophysiology|Pathophysiology]]== |
| ===Incidence===
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| *The [[incidence]] of [[anorectal abscess]] is estimated to be around 68,000 to 96,000 cases per year in the United States.<ref name="pmid22379401">{{cite journal| author=Abcarian H| title=Anorectal infection: abscess-fistula. | journal=Clin Colon Rectal Surg | year= 2011 | volume= 24 | issue= 1 | pages= 14-21 | pmid=22379401 | doi=10.1055/s-0031-1272819 | pmc=3140329 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22379401 }} </ref>
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| ===Gender=== | | ==[[Roseola causes|Causes]]== |
| *Anorectal abscesses are two times more frequently seen in men than women.<ref name="pmid22362468">{{cite journal| author=Ommer A, Herold A, Berg E, Fürst A, Sailer M, Schiedeck T| title=German S3 guideline: anal abscess. | journal=Int J Colorectal Dis | year= 2012 | volume= 27 | issue= 6 | pages= 831-7 | pmid=22362468 | doi=10.1007/s00384-012-1430-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22362468 }} </ref>
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| ===Age=== | | ==[[Roseola differential diagnosis|Differentiating Any Disease from other Diseases]]== |
| *Patients with anal abscess present between ages of 20 to 60 years with a mean age of 40 in both sexes.<ref name="pmid22379401">{{cite journal| author=Abcarian H| title=Anorectal infection: abscess-fistula. | journal=Clin Colon Rectal Surg | year= 2011 | volume= 24 | issue= 1 | pages= 14-21 | pmid=22379401 | doi=10.1055/s-0031-1272819 | pmc=3140329 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22379401 }} </ref>
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| ===Race===
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| *There are limited epidemiological studies which studied the frequency of anal abscess with race differences, however a study in Chicago reported a 92% of the patients presented with anal abscess were of African American origin.<ref name="pmid527452">{{cite journal| author=Read DR, Abcarian H| title=A prospective survey of 474 patients with anorectal abscess. | journal=Dis Colon Rectum | year= 1979 | volume= 22 | issue= 8 | pages= 566-8 | pmid=527452 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=527452 }} </ref>
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| ==Risk Factors== | | ==[[Roseola epidemiology and demographics|Epidemiology and Demographics]]== |
| Risk factors for the development of recurrent of anal abscesses include<ref name="pmid26768004">{{cite journal| author=Adamo K, Sandblom G, Brännström F, Strigård K| title=Prevalence and recurrence rate of perianal abscess--a population-based study, Sweden 1997-2009. | journal=Int J Colorectal Dis | year= 2016 | volume= 31 | issue= 3 | pages= 669-73 | pmid=26768004 | doi=10.1007/s00384-015-2500-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26768004 }} </ref>:
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| *[[Crohn's disease]]
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| *[[Diabetes mellitus]]
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| *History of abscess in the ischiorectal location
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| *[[HIV infection]]
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| *Receptive anal sex
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| ==Differential Diagnosis== | | ==[[Roseola risk factors|Risk Factors]]== |
| Anorectal abscess must be differentiated from other causes of anal pain including anal fissure, thrombosed hemorrhoids, levator spasm, sexually transmitted disease, proctitis, and hidradenitis suppurativa, infected skin furuncles, herpes simplex virus, HIV, tuberculosis, syphilis,and actinomycosis
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| *Cancer<ref name="pmid26805351">{{cite journal| author=Adikrisna R, Udagawa M, Sugita Y, Ishii T, Okamoto H, Yabata E| title=[A Case of Squamous Cell Carcinoma of the Anal Canal with a Perianal Abscess]. | journal=Gan To Kagaku Ryoho | year= 2015 | volume= 42 | issue= 12 | pages= 2322-4 | pmid=26805351 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26805351 }} </ref>
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| ==Natural History, Prognosis, Complications== | | ==[[Roseola screening|Screening]]== |
| ===Natural History===
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| ===Complications=== | | ==[[Roseola natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| *Recurrence usually to incomplete drainage of the abscess
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| *[[Sepsis]]
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| *[[Fistula]] formation
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| *Scarring
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| ==Diagnosis== | | ==Diagnosis== |
| ===History and Symptoms===
| | [[Roseola history and symptoms|History and Symptoms]] | [[Roseola physical examination|Physical Examination]] | [[Roseola laboratory findings|Laboratory Findings]] | [[Roseola electrocardiogram|Electrocardiogram]] | [[Roseola chest x ray|Chest X Ray]] | [[Roseola CT|CT]] | [[Roseola MRI|MRI]] | [[Roseola echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Roseola other imaging findings|Other Imaging Findings]] | [[Roseola other diagnostic studies|Other Diagnostic Studies]] |
| *Patients with low abscess typically present with anal pain. Other associated findings include:
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| **[[Anal pain]]
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| **[[Pain]] associated with bowel movements: It is worse when the person sits down and right before a bowel movement. After the individual has a bowel movement, the pain usually lessens.<ref>{{cite book | last = Ferri | first = Fred | title = Ferri's clinical advisor 2015 : 5 books in 1 | publisher = Elsevier/Mosby | location = Philadelphia, PA | year = 2015 | isbn = 978-0323083751 }}</ref>
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| **Swelling
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| **[[Chills]]
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| **[[Constipation]]
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| **[[pus|Discharge of pus]] from the [[rectum]]
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| **[[Fever]]
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| *Patients with high abscess present with :
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| **[[Fever]]
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| **[[Malaise]]
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| **[[Anal pain]]
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| ===Physical Examination===
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| ====General Appearance====
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| *Patients with high abscess present with [[fever]], elevated body temperature can be noticed.
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| ====Digital Rectal Examination====
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| *It is difficult to perform [[digital rectal examination]] due to the severe pain, therefore patient should be examined under [[local anesthesia]] to identify the location of the abscess and also if suspicion of a high abscess (Supralevator abscess) is present.
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| *[[Anoscopy]] should not be performed.<ref name="pmid27723447">{{cite journal| author=Chang J, Mclemore E, Tejirian T| title=Anal Health Care Basics. | journal=Perm J | year= 2016 | volume= 20 | issue= 4 | pages= 74-80 | pmid=27723447 | doi=10.7812/TPP/15-222 | pmc=5101094 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27723447 }} </ref>
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| *Anal abscess is a clinical diagnosis and presence of [[induration]], [[tenderness]] and [[fluctulance]] are diagnostic of perianal and ishciorectal abscess. In patients with intersphincteric or supralevator abscesses external findings are minimal only pelvic or rectal [[tenderness]] or [[fluctulance]] on [[digital rectal examination]] can be demonstrated.
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| Physical examination findings demonstrated in anorectal abscess include:
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| *[[Erythema]]
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| *[[Warmth]]
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| *[[Tenderness]]
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| *[[Induration]]
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| *[[Fluctulance]]
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| <div align="left">
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| <gallery heights="175" widths="175">
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| Image:Gu perirectal abscess2.jpg|Perianal abscess
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| Image:Gu perirectal abscess.jpg|Perianal abscess
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| </gallery>
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| </div>
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| <small>(Images courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, CA)</small>
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| ===Laboratory Findings===
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| ===Imaging===
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| ====Ultrasound====
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| *Endoanal [[ultrasound]] is useful in detecting horse-shoe abscesses extension and presence of [[fistula]] tracts with high sensitivity.
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| *[[Three dimensional ultrasound]] is useful in patients to identify the anatomical locations of complex perianal abscesses and [[fistula]] tracts.
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| ====CT Scan====
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| *[[CT scan]] is useful in patients with complex suppurative anorectal conditions such as supralevator abscess and to identify other etiologies causing anorectal abscess such as pelvic infections, [[appendicitis]], [[Crohn's disease]] and [[diverticulitis]].
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| ==Treatment== | | ==Treatment== |
| ===Medical Therapy===
| | [[Roseola medical therapy|Medical Therapy]] | [[Roseola surgery|Surgery]] | [[Roseola primary prevention|Primary Prevention]] | [[Roseola secondary prevention|Secondary Prevention]] | [[Roseola cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Roseola future or investigational therapies|Future or Investigational Therapies]] |
| *Medical therapy is not recommended in patients with anal abscess as the [[antibiotics]] have poor penetration in to the abscess cavity and are not helpful to in treatment of the infection or [[wound healing]].
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| *[[Antibiotics]] may be considered in patients with extensive [[cellulitis]], [[HIV infection]] and [[diabetes mellitus]].
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| *Patients with low [[neutrophil]] count (500-1000/mm³) and also in patients with no fluctulance medical therapy can be helpful in resolution of the abscess, however in patients with [[neutrophil]] count of >1000/mm³ and with fluctulance surgical drainage is a better option for treatment.
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| *[[Prophylactic antibiotics]] prior to [[incision and drainage]] is recommended by [[American Heart Association]], in patients with [[prosthetic valves]], previous [[bacterial endocarditis]], [[congenital heart disease]], and [[heart transplant]] recipients with valve pathology.
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| ===Surgical Therapy===
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| *Management of anal abscess should be prompt as the risk of involving the surrounding tissue resulting in perineal [[cellulitis]] and [[sepsis]] is high.<ref name="pmid24881481">{{cite journal| author=Slauf P, Antoš F, Marx J| title=[Acute periproctal abscesses]. | journal=Rozhl Chir | year= 2014 | volume= 93 | issue= 4 | pages= 226-31 | pmid=24881481 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24881481 }} </ref>
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| *Primary treatment for anorectal abscess is [[incision and drainage]] and it should be performed within 24 hours of presentation.
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| *Patients with perianal abscess and ischiorectal abscess can be treated in a [[outpatient]] setting under local anesthesia using 1% [[lidocaine]] with [[epinephrine]] (and [[bupivacaine]] for extended analgesia), is injected [[subcutaneously]] into the area affected by the abscess to provide adequate infilteration into the [[skin]].
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| *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.
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| ====Procedure====
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| *Under aseptic precautions a [[scalpel]] is used to make a [[cruciate]] or [[elliptical]] incision over the area of flactulance. The incision should be close to the [[anal verge]] to minimize the length of a potential [[fistula]].
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| *After incising the necrotic tissue is removed and loculations are broken using a [[hemostat]].
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| *After the procedure the wound is packed with a gauze sponge which is removed after 24 hours.<ref name="pmid27562822">{{cite journal| author=Smith SR, Newton K, Smith JA, Dumville JC, Iheozor-Ejiofor Z, Pearce LE et al.| title=Internal dressings for healing perianal abscess cavities. | journal=Cochrane Database Syst Rev | year= 2016 | volume= | issue= 8 | pages= CD011193 | pmid=27562822 | doi=10.1002/14651858.CD011193.pub2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27562822 }} </ref>
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| *Regular [[sitz bath]] is recommended after the surgery, it will help in local cleansing and wound healing.
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| *A variation in the incision of drainage is by using a small latex catheter (Pezzer catheter). After a small incision is made the catheter is inserted into the cavity and is left in place for a duration of 3 to 10days till the [[abscess]] cavity is drained and the cavity closes around the catheter.
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| ====Complications====
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| *Recurrence of the abscess: The recurrence rate depends on the location of the abscess and the length of follow-up, the rate ranges from 3% to 44%. Other factors influencing the recurrence rate include incomplete initial drainage, failure to break up loculations within the abscess, missed abscess undiagnosed [[fistula]]. Recurrence rates are high in horseshoe abscess with a range from 18% to 50% which require multiple surgeries.
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| *[[Urinary retention]]
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| *Postoperative [[bleeding]]
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| ==Prevention==
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| ===Primary Prevention===
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| ===Secondary Prevention===
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| ==References== | | ==Case Studies== |
| {{Reflist|2}}
| | [[Roseola case study one|Case #1]] |