- Email: [email protected]
Ischiorectal abscess
ISCHIORECTAL MARION
C.
PRUITT,
M.D.,
ABSCESS F.R.c.s.,
P.A.C.S.
Associate in Surgery (Proctology), Emory University SchooI of Medicine ATLANTA,
A
CUTE
abscess in the anorecta1 region is usually due to infection by the common pyogenic organisms foIIowing irritation, traumatism, inffammation, or uIceration in the ana cana1. It has its point of origin most often at the pectinate Iine in one of the ana crypts. In reIation to the anus and rectum, abscess occurs in various anatomic Iocations, thus : I. If the infection extends upwards in the recta1 waI1 the abscess originates in the submucosa. This Iocation is rare. 2. UsuaIIy the abscess is outside the gut waI1 in one of three positions: (a) Above the pelvic diaphragm in the superior perirectal space. (b) Subcutaneous around the anus. (c) In the ischiorectal fossa. Of the above Iocations the most frequent position of abscess in the anorecta1 region is in the ischiorecta1 fossa. CAUSE
OF ISCHIORECTAL
ABSCESS
Besides chemical irritation and traumatism caused by the passage of bowe1 contents to the Iower part of the rectum and anus, ischiorecta1 abscess may foIIow injury 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
GEORGIA
posterior ana fissure. They aIso may be caused by stranguIated, gangrenous, infected hemorrhoids. OccasionaIIy abscess may foIIow anorecta1 operations due to spread of infection into deeper tissues but most often postoperative infection gives rise to a subcutaneous type of abscess. In addition to the above causes infection and uIceration may originate in the ana crypts and terminate in ischiorecta1 abscess. TubercIe baciIIus, gonococcus, and Vincent’s organisms may be considered as causes. AIso an infection of an abrasion of the skin or acute inffammation of periana1 skin without abrasion or uIceration may through the Iymphatics terminate in an ischiorecta1 abscess. Infection may occur by direct extension from retrorecta1 or superior peIvirecta1 spaces, or from urogenital organs. SPREAD
When an abscess originates in the ischiorecta1 fossa it spreads through the Ioose adipose tissue without causing any obvious sweIIing unti1 considerabIe tension is present. 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 junction 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 to resistance : it may trave1 downward open on the skin surface, or aIong the anal
670
A unerican Journd
of
Surgery
Pruitt-IschiorectaI
fascia, which is porti :on of the Ievator direc :tIy attached to the muscuIar coats of th le a na1 cana between the two sphinc-
FIG. I. Photograph
Abscess
posterior fissure or infection of an ana crypt. A peIvirecta1 abscess may rupture into the ischiorecta1 fossa and in this way
and drawing of a large acute ischiorecta1
ters, to open into the ana cana at the anorecta1 junction. However the infection may spread directIy through the posterior passageway between the sphincters behind the rectum to the opposite side. Infection in the ana cana1, especiaIIy aIong the pectinate Iine posteriorIy, may pass through the Iymphatics to either fossa or to both, though the infection usuaIIy deveIops more rapidIy on one side than the other. When both sides are invoIved it is known as a “dumbbeI1” abscess : such an abscess tends to terminate in a “horseshoe” fistuIa with the interna opening Iocated at the posterior midIine in the ana crypt. This indicates that the origin of the infection which terminates in an ischiorecta1 abscess was probabIy a
DE<
abscess.
cause a peIvirecto-ischiorecta1 abscess. It is rare for an ischiorecta1 abscess to extend upwards into the peIvirecta1 space. In some cases it may extend between the sphincters upwards and form a submucous abscess. The ischiorecta1 fossa is pyramida in shape and is situated on each side of the anus and Iower part of rectum externa1 to the sphincter muscIes. Under extreme tension it may distend to hoId 4 to 8 ounces of pus. When more than this is evacuated one must suspect that an abscess in the superior peIvirecta1 space has perforated through the Ievator ani, forming a secondary ischiorecta1 abscess. The combined Iocations makes a condition very compIicated and diffxcuIt to treat.
NEW
SERIES VOL.
XLVI,
No.
3
Pruitt-IschiorectaI
The possibihty of tuberculous abscess in the ischiorecta1 fossa wiI1 not be discussed in this paper as it is rare: such abscesses
Abscess
American
Journal
of Surgery
671
At first there are no apparent Iocal signs but soon induration may be feIt aIong the 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 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.
IocaI temperature, redness and discoloration, 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
TREATMENT
From the etioIogic factors invoIved one may appreciate the importance of preven-
Abscess
DECEMBER, 19x1
the patient more comfortable. However, to temporize with such measures in hope that 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 both constipation and of drastic purgatives, the avoidance of injury from enema tips, and care not to swaIIow seeds or other foreign bodies. It also is important to cIear up IocaI pathoIogy. When an ischiorecta1 abscess has deveIoped, onIy one method of treatment shouId be considered: nameIy, opening and draining the abscess at once. As soon as the tension is reIieved the abscess ceases to spread and an earIy incision may prevent subsequent fistuIa. LittIe if any resuIt shouId be expected from the common use of recta1 suppositories. If for some reason operation cannot be done immediateIy, hot fomentations and hot sitz baths tend to reIieve pain and make
for the abscess to open spontaneousIy proIongs the patient’s suffering and as the size of the abscess increases, it means heaIing wiI1 be proIonged and a f%tuIa wiI1 aImost certainIy foIIow. In cases where the induration and tumefaction are such as to bring up the question of gas gangrene infection, it seems wiser to administer suIfaniIamide in Iarge doses and wait. Often suIfaniIamide gives reIief of symptoms and causes the acute infection to subside. Then foIIows genera1 improvement of the patient. CertainIy this method of treatment is advisabIe unti1 the question of gas gangrene is cIeared up, as incision into such infection before pus formation is of doubtfu1 vaIue and may 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 incompIete and at times Iimits the operation. Never use ethy1 chIoride spray, as the anesthesia is incompIete, the extent of 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 established 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 introduced 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: 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 hemorrhage. 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 patient 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, promoting 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 sphincter 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.
C.
PRUITT,
M.D.,
ABSCESS F.R.c.s.,
P.A.C.S.
Associate in Surgery (Proctology), Emory University SchooI of Medicine ATLANTA,
A
CUTE
abscess in the anorecta1 region is usually due to infection by the common pyogenic organisms foIIowing irritation, traumatism, inffammation, or uIceration in the ana cana1. It has its point of origin most often at the pectinate Iine in one of the ana crypts. In reIation to the anus and rectum, abscess occurs in various anatomic Iocations, thus : I. If the infection extends upwards in the recta1 waI1 the abscess originates in the submucosa. This Iocation is rare. 2. UsuaIIy the abscess is outside the gut waI1 in one of three positions: (a) Above the pelvic diaphragm in the superior perirectal space. (b) Subcutaneous around the anus. (c) In the ischiorectal fossa. Of the above Iocations the most frequent position of abscess in the anorecta1 region is in the ischiorecta1 fossa. CAUSE
OF ISCHIORECTAL
ABSCESS
Besides chemical irritation and traumatism caused by the passage of bowe1 contents to the Iower part of the rectum and anus, ischiorecta1 abscess may foIIow injury 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
GEORGIA
posterior ana fissure. They aIso may be caused by stranguIated, gangrenous, infected hemorrhoids. OccasionaIIy abscess may foIIow anorecta1 operations due to spread of infection into deeper tissues but most often postoperative infection gives rise to a subcutaneous type of abscess. In addition to the above causes infection and uIceration may originate in the ana crypts and terminate in ischiorecta1 abscess. TubercIe baciIIus, gonococcus, and Vincent’s organisms may be considered as causes. AIso an infection of an abrasion of the skin or acute inffammation of periana1 skin without abrasion or uIceration may through the Iymphatics terminate in an ischiorecta1 abscess. Infection may occur by direct extension from retrorecta1 or superior peIvirecta1 spaces, or from urogenital organs. SPREAD
When an abscess originates in the ischiorecta1 fossa it spreads through the Ioose adipose tissue without causing any obvious sweIIing unti1 considerabIe tension is present. 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 junction 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 to resistance : it may trave1 downward open on the skin surface, or aIong the anal
670
A unerican Journd
of
Surgery
Pruitt-IschiorectaI
fascia, which is porti :on of the Ievator direc :tIy attached to the muscuIar coats of th le a na1 cana between the two sphinc-
FIG. I. Photograph
Abscess
posterior fissure or infection of an ana crypt. A peIvirecta1 abscess may rupture into the ischiorecta1 fossa and in this way
and drawing of a large acute ischiorecta1
ters, to open into the ana cana at the anorecta1 junction. However the infection may spread directIy through the posterior passageway between the sphincters behind the rectum to the opposite side. Infection in the ana cana1, especiaIIy aIong the pectinate Iine posteriorIy, may pass through the Iymphatics to either fossa or to both, though the infection usuaIIy deveIops more rapidIy on one side than the other. When both sides are invoIved it is known as a “dumbbeI1” abscess : such an abscess tends to terminate in a “horseshoe” fistuIa with the interna opening Iocated at the posterior midIine in the ana crypt. This indicates that the origin of the infection which terminates in an ischiorecta1 abscess was probabIy a
DE<
abscess.
cause a peIvirecto-ischiorecta1 abscess. It is rare for an ischiorecta1 abscess to extend upwards into the peIvirecta1 space. In some cases it may extend between the sphincters upwards and form a submucous abscess. The ischiorecta1 fossa is pyramida in shape and is situated on each side of the anus and Iower part of rectum externa1 to the sphincter muscIes. Under extreme tension it may distend to hoId 4 to 8 ounces of pus. When more than this is evacuated one must suspect that an abscess in the superior peIvirecta1 space has perforated through the Ievator ani, forming a secondary ischiorecta1 abscess. The combined Iocations makes a condition very compIicated and diffxcuIt to treat.
NEW
SERIES VOL.
XLVI,
No.
3
Pruitt-IschiorectaI
The possibihty of tuberculous abscess in the ischiorecta1 fossa wiI1 not be discussed in this paper as it is rare: such abscesses
Abscess
American
Journal
of Surgery
671
At first there are no apparent Iocal signs but soon induration may be feIt aIong the 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 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.
IocaI temperature, redness and discoloration, 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
TREATMENT
From the etioIogic factors invoIved one may appreciate the importance of preven-
Abscess
DECEMBER, 19x1
the patient more comfortable. However, to temporize with such measures in hope that 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 both constipation and of drastic purgatives, the avoidance of injury from enema tips, and care not to swaIIow seeds or other foreign bodies. It also is important to cIear up IocaI pathoIogy. When an ischiorecta1 abscess has deveIoped, onIy one method of treatment shouId be considered: nameIy, opening and draining the abscess at once. As soon as the tension is reIieved the abscess ceases to spread and an earIy incision may prevent subsequent fistuIa. LittIe if any resuIt shouId be expected from the common use of recta1 suppositories. If for some reason operation cannot be done immediateIy, hot fomentations and hot sitz baths tend to reIieve pain and make
for the abscess to open spontaneousIy proIongs the patient’s suffering and as the size of the abscess increases, it means heaIing wiI1 be proIonged and a f%tuIa wiI1 aImost certainIy foIIow. In cases where the induration and tumefaction are such as to bring up the question of gas gangrene infection, it seems wiser to administer suIfaniIamide in Iarge doses and wait. Often suIfaniIamide gives reIief of symptoms and causes the acute infection to subside. Then foIIows genera1 improvement of the patient. CertainIy this method of treatment is advisabIe unti1 the question of gas gangrene is cIeared up, as incision into such infection before pus formation is of doubtfu1 vaIue and may 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 incompIete and at times Iimits the operation. Never use ethy1 chIoride spray, as the anesthesia is incompIete, the extent of 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 established 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 introduced 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: 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 hemorrhage. 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 patient 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, promoting 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 sphincter 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.