• Result from occlusion of anal glands and crypts at the dentate line
• Occlusion may follow impaction of vegetable matter or edema from trauma
• Abscesses are classified according to space they invade
• May also develop as a result of inflammatory bowel disease (Crohn)
• Fistula-in-ano from the anus to the perianal skin develops when abscess cavity maintains persistent communication with the crypt
• Goodsall rule: Used to identify direction of fistula tract
• Severe anal/perianal pain, usually continuous and throbbing
• Pain may worsen with movement and straining
• Swelling and discharge may be noted
• Patients may have fever, urinary retention
• Severe, life-threatening perineal sepsis may develop
• Patients with fistula-in-ano may have pain and bloody discharge
• Exam findings may include tender perianal or rectal mass
• Fistula: Internal and external openings with mucopurulent drainage
• Fistulous tract is often palpable and firm
• May have elevated WBC count, especially with perineal sepsis
• Drainage may have white blood cells, bacteria
• Imaging studies are unnecessary in uncomplicated cases
• Sinogram may reveal fistulous tract and branches
• Transrectal US may reveal extent of sphincter involvement
• CT scan may be helpful in identifying supralevator abscesses
• Crohn disease
• Anorectal malignancy
• Abscesses should be drained; admission will depend on extent of abscess drainage required
• Signs of perineal sepsis or complicated abscess
• Fistula-in-ano by itself is not a surgical emergency
• Treatment for abscess is surgical drainage
• Intersphincteric abscesses are treated with internal sphincterotomy
• Perianal and ischiorectal abscesses are drained through the perianal skin
• Fistula-in-ano: Fistulotomy, currette tract and granulation tissue, heal by secondary intention
• Fistula-in-ano: Involving external sphincter may be treated with seton placement or drainage with delayed repair with an endorectal advancement flap
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