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Background
Ananorectalabscessoriginatesfromaninfectionarisinginthecryptoglandular
epitheliumliningtheanalcanal.Theinternalanalsphincterisbelievedtoserve
normallyasabarriertoinfectionpassingfromthegutlumentothedeepperirectal
tissues.ThisbarriercanbebreachedthroughthecryptsofMorgagni,whichcan
penetratethroughtheinternalsphincterintotheintersphinctericspace.
Onceinfectiongainsaccesstotheintersphinctericspace,ithaseasyaccesstothe
adjacentperirectalspaces.Extensionoftheinfectioncaninvolvetheintersphincteric
space,ischiorectalspace,oreventhesupralevatorspace.Insomeinstances,the
abscessremainscontainedwithintheintersphinctericspace.Theseverityanddepth
oftheabscessarequitevariable,andtheabscesscavityisoftenassociatedwith
formationofafistuloustract.Forthatreason,fistulasarealsodiscussedinthis
articlewhererelevant.
Thevarietyofanatomicsequelaeoftheprimaryinfectionistranslatedintovariable
clinicalpresentations.Therelativelysimpleperianalabscessistobedistinguished
fromthemorecomplexperirectalabscesses.Treatmentalsodiffersaccordingtothe
typeofabscesspresent.
Forpatienteducationresources,seetheEsophagus,Stomach,andIntestine
CenterandtheDigestiveDisordersCenter,aswellasAnalAbscess,RectalPain,
andRectalBleeding.

Anatomy
Normalanatomydemonstratesanywherefrom410analglandslyingatthelevelof
thedentateline,whichdividesthesquamousepitheliumdistallyandthecolumnar
epitheliumproximally.Obstructionoftheseanalglandsbydebrisleadstostasis,
bacterialovergrowth,andabscessformationthatextendsintotheintersphincteric
groovebetweentheinternalandexternalanalsphincters. [1]Fromthisspace,the
abscesscanspreadalongvariouspotentialspaces.
Anorectalabscessesareclassifiedaccordingtotheiranatomiclocationthe
followingarethemostcommonlocations(seetheimagebelow):
Perianal
Ischiorectal
Intersphincteric
Supralevator

Illustrationofmajortypesofanorectalabscesses(submucosaltypenotpictured).

Perianalabscessesrepresentthemostcommontypeofanorectalabscesses,
accountingforapproximately60%ofreportedcases. [1,2,3,4]Thesesuperficial
collectionsofpurulentmaterialarelocatedbeneaththeskinoftheanalcanaland
donottransversetheexternalsphincter.
Ischiorectalabscessesarethenextmostcommontype.Theseabscessesform
whensuppurationtransversestheexternalanalsphincterintotheischiorectalspace.
Anischiorectalabscessmaytraversethedeeppostanalspaceintothecontralateral
side,formingasocalledhorseshoeabscess.
Intersphinctericabscesses,thethirdmostcommontype,resultfromsuppuration
containedbetweentheinternalandexternalanalsphincters.Theymaylie
completelywithintheanalcanal,leadingtoseverepain,andmayonlybefoundby
digitalrectalexaminationoranoscopy.

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Supralevatorabscesses,theleastcommonofthefourmajortypes,mayformfrom
cephaladextensionoftheintersphinctericabscessabovethelevatoraniorfrom
caudalextensionofasuppurativeabdominalprocess(eg,appendicitis,diverticular
disease,gynecologicsepsis)intothesupralevatorspace.Theseabscessesmaybe
diagnosedbymeansofcomputedtomography(CT),andtheycausepelvicand
rectalpain.
AccordingtothewidelyusedParksclassificationsystem,anorectalfistulasmayalso
beclassifiedintofourmajortypes,asfollows[5]:
Intersphincteric(70%)Foundbetweentheinternalandexternalsphincters
Transsphincteric(23%)Extendsthroughtheexternalsphincterintothe
ischiorectalfossa
Extrasphincteric(5%)Passesfromtherectumtotheskinthroughthe
levatorani
Suprasphincteric(2%)Extendsfromtheintersphinctericplanethroughthe
puborectalis,exitingtheskinaftertraversingthelevatorani
Thecharacteristicsofperianalfistulasvaryaccordingtotheiranatomiclocation.
AccordingtotheGoodsallrule,theexternalopeningofafistuloustractlocated
anteriortoatransverselinedrawnacrosstheanalvergeisassociatedwitha
straightradialtractofthefistulaintotheanalcanal/rectum,whereasanexternal
openingposteriortothetransverselinefollowsacurved,fistuloustracttothe
posteriormidlineoftherectallumen(seetheimagebelow).Thisruleisimportant
forplanningsurgicaltreatmentofthefistula(seeTreatment).

Goodsallruleforanorectalfistulas.Fistulasthatexitinposteriorhalfofrectumgenerallyfollow
curvedcoursetowardposteriormidline,whereasthosethatexitinanteriorhalfofrectumusually
followradialcoursetodentateline.

PathophysiologyandEtiology
Perirectalabscessesandfistulasrepresentanorectaldisordersarisingpredominantly
(~90%ofcases)fromtheobstructionofanalcrypts, [4]possiblyinvolvingincreased
sphinctertone. [6]Infectionofthenowstaticglandularsecretionsresultsin
suppurationandabscessformationwithintheanalgland.Typically,theabscess
formsinitiallyintheintersphinctericspaceandthenspreadsalongadjacent
potentialspaces.
Bothaerobicandanaerobicbacteriahavebeenfoundtoberesponsibleforabscess
formation.TheanaerobesmostcommonlyimplicatedareBacteroidesfragilis,
Peptostreptococcus,Prevotella,Fusobacterium,Porphyromonas,andClostridium.
TheaerobesmostcommonlyimplicatedareStaphylococcusaureus,Streptococcus,
andEscherichiacoli. [7]Morerecentstudieshavenotedcommunityacquired
methicillinresistantSaureus(MRSA)asapathogenleadingtoabscessformation.
[8,9]

Approximately10%ofanorectalabscessesmaybecausedbyreasonsotherthan
analglandinfection,includingCrohndisease,trauma,immunodeficiencyresulting
fromHIVinfectionormalignancy(bothhematologicandanorectalcancer),
tuberculosis,hidradenitissuppurativa,sexuallytransmitteddiseases,radiation
therapy,foreignbodies,perforateddiverticulardisease,inflammatoryboweldisease,
orappendicitis(ararecauseofsupralevatorabscesses). [1]

Epidemiology
UnitedStatesandinternationalstatistics
Approximately30%ofpatientswithanorectalabscessesreportaprevioushistoryof
similarabscessesthateitherresolvedspontaneouslyorrequiredsurgical

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intervention.
Theincidenceofabscessformationappearstobehigherinspringandsummer.
Whereasdemographicspointtoacleardisparityintheoccurrenceofanal
abscesseswithrespecttoageandsex,noobviouspatternexistsamongvarious
countriesorregionsoftheworld.Althoughithasbeensuggestedthatthereisa
directrelationbetweentheformationofanorectalabscessesandbowelhabits,
frequentdiarrhea,andpoorpersonalhygiene,thisrelationremainsunproven.

Ageandsexrelateddemographics
Thepeakincidenceofanorectalabscessesisinthethirdandfourthdecadesoflife.
[10]Theseabscessesarealsoquitecommonininfants(seeAnorectalAbscessesin
Children).Theexactmechanismispoorlyunderstoodbutdoesnotappeartobe
relatedtoconstipation.Fortunately,thisconditionisquitebenignininfants,rarely
necessitatinganyoperativeinterventionotherthansimpledrainage. [11]
Menareaffectedmorefrequentlythanwomenare,withamaletofemale
predominanceof2:1to3:1. [10]

Prognosis
Overallmortalityfromanorectalabscessesisquitelow. [2]
Earlydataindicatedthatabscessformationrecurredinapproximately10%of
patients,withchronicfistulainanooccurringinasmany50%ofpatients. [1,2,12]A
laterstudyfoundthat37%ofpatientsdevelopedchronicanalfistulaorrecurrent
sepsis. [6]Inthisstudy,riskfactorswereageyoungerthan40yearsandnondiabetic
statusnodifferenceinthesecomplicationswasnotedwithregardtoHIVstatus,
sex,antibioticusage,orsmokingstatus.
Approximatelytwothirdsofpatientswithrectalabscesseswhoaretreatedby
incisionanddrainageorbyspontaneousdrainagewilldevelopachronicanalfistula.
Afterfistulaformation,multiplecomplicationsmaydevelopaftersurgery.Asmany
as43%ofpatientsmayexperiencefecalincontinenceaftersurgicalrepairfor
complexfistulainano. [13]Otherpostoperativecomplicationsincludetemporary
postejaculationurethralirritationandpostoperativeurinaryretention. [14]
Constipationmayalsooccurasaresultofpainondefecation.
Therecurrencerateofanorectalfistulasafterfistulotomy,fistulectomy,ortheuseof
asetonisabout1.5%.Thesuccessrateofprimarysurgicaltreatmentwith
fistulotomyappearstobefairlygood. [15]

AnorectalAbscess
ClinicalPresentation

Author:AndreHebra,MDChiefEditor:JohnGeibel,MD,DSc,MSc,MAmore...
ContributorInformationandDisclosures
Updated:Oct30,2014
Author
AndreHebra,MDChief,DivisionofPediatricSurgery,ProfessorofSurgeryandPediatrics,MedicalUniversityof
SouthCarolinaCollegeofMedicineSurgeoninChief,MedicalUniversityofSouthCarolinaChildren'sHospital
AndreHebra,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,FloridaMedical
Association,SocietyofAmericanGastrointestinalandEndoscopicSurgeons,Children&#039sOncologyGroup,
InternationalPediatricEndosurgeryGroup,AmericanAcademyofPediatrics,AmericanCollegeofSurgeons,
AmericanMedicalAssociation,AmericanPediatricSurgicalAssociation,SocietyofLaparoendoscopicSurgeons,
SouthCarolinaMedicalAssociation,SoutheasternSurgicalCongress,SouthernMedicalAssociation
Disclosure:Nothingtodisclose.
ChiefEditor
JohnGeibel,MD,DSc,MSc,MAViceChairandProfessor,DepartmentofSurgery,SectionofGastrointestinal
Medicine,andDepartmentofCellularandMolecularPhysiology,YaleUniversitySchoolofMedicineDirector,
SurgicalResearch,DepartmentofSurgery,YaleNewHavenHospitalAmericanGastroenterologicalAssociation
Fellow
JohnGeibel,MD,DSc,MSc,MAisamemberofthefollowingmedicalsocieties:AmericanGastroenterological
Association,AmericanPhysiologicalSociety,AmericanSocietyofNephrology,AssociationforAcademic
Surgery,InternationalSocietyofNephrology,NewYorkAcademyofSciences,SocietyforSurgeryofthe
AlimentaryTract
Disclosure:ReceivedroyaltyfromAMGENforconsultingReceivedownershipinterestfromArdelyxfor
consulting.
Acknowledgements
MarcDBasson,MD,PhD,MBA,FACSProfessor,Chair,DepartmentofSurgery,AssistantDeanforFaculty
DevelopmentinResearch,MichiganStateUniversityCollegeofHumanMedicine
MarcDBasson,MD,PhD,MBA,FACSisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanCollegeofSurgeons,AmericanGastroenterologicalAssociation,PhiBetaKappa,andSigmaXi
Disclosure:Nothingtodisclose.
MichaelSBeeson,MD,MBA,FACEPProfessorofEmergencyMedicine,NortheasternOhioUniversities
CollegeofMedicineandPharmacyAttendingFaculty,AkronGeneralMedicalCenter
MichaelSBeeson,MD,MBA,FACEPisamemberofthefollowingmedicalsocieties:AmericanCollegeof
EmergencyPhysicians,CouncilofEmergencyMedicineResidencyDirectors,NationalAssociationofEMS

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Physicians,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
StevenCDronen,MD,FAAEMChair,DepartmentofEmergencyMedicine,LeConteMedicalCenter
StevenCDronen,MD,FAAEMisamemberofthefollowingmedicalsocieties:AmericanAcademyof
EmergencyMedicineandSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergency
Medicine,CharlesDrewUniversityofMedicineandScienceFormerChair,DepartmentofEmergencyMedicine,
MartinLutherKingJr/DrewMedicalCenter
Disclosure:Nothingtodisclose.
NizarKifaieh,MD,FACEPAssistantProfessor,MedicalDirector,DepartmentOfEmergencyMedicine,State
UniversityofNewYorkDownstateMedicalCenter
NizarKifaieh,MD,FACEPisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergency
Medicine,AmericanCollegeofEmergencyPhysicians,AmericanCollegeofPhysicianExecutives,American
MedicalAssociation,NewYorkCountyMedicalSociety,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment
PatrickBThomas,MDFellow,DepartmentofPediatricSurgery,TexasChildren'sHospital
Disclosure:Nothingtodisclose.
WalterWValeskyJr,MDClinicalAssistantInstructor,DepartmentofEmergencyMedicine,KingsCounty
Hospital,StateUniversityofNewYorkDownstateMedicalCenter
Disclosure:Nothingtodisclose.

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