Research Article

The Pattern and Management of Gluteal Abscess Disease at

Al-Yarmouk Teaching Hospital
Haqqi I. Razzouki CABS ,Sattar J. Kadhim CABS, MRCS , Amer H.Salman CABS,DS

Date Submitted:31-10-2012
Date Accepted: 1-07-2013
Address for Correspondence:
Haqqi I. Razzouki
Department of General
Surgery, Al-Yarmouk
Teaching Hospital
Abstract
Background: Despite the improvement in health care in general and
antiseptic techniques in particular, cases of gluteal abscess following intra-
muscular injections are still encountered. Although this condition is not
considered a serious illness, still it causes complications and exerts a pressure
on health resources.
Objectives: To determine the factors responsible for the development of
gluteal abscesses and to suggest measures to avoid this problem and to study
the methods used in management.
Methods: This is a prospective analytic study in which all patients admitted
to the surgical ward with gluteal abscess over a six months period were
included. Detailed demographic, clinical and investigative data were
recorded. Predisposing factors and co-morbid conditions were documented,
also, the persons who did the injection, the types of drugs used and other
factors related to the process of injection were studied. The contribution of
the human, technical and pharmacological elements were analysed. The
methods used in management, early post-operative complications and the
final outcome were recorded.
Results: Forty-two patients were included in the study; of those, 30 were
females (75%) and the mean age was 35 years. Eighteen were diabetic
(42.8%) and 16 (38.04%) were over-weight. Thirty-eight patients (90.47%)
had history of preceding intra-muscular injections. Most of the drugs used
were antibiotics, mainly Cefotaxime used in 14 patients (33.33%). There was
also 8 instances related to Diclofenac injection (19.04%) and 4 related to iron
preparation (9.5%). There were 8 instances of mixed injections using more
than one drug (19.04%). Twenty-eight episodes were related to under-
trained personnel (66.67%); 20 female nurses (47.62%) and 8 male nurses
(19%). Forty patients presented mainly as local pain(97%) and 36 patient as
visible swelling(90%). The main method of diagnosis was clinical. All patients
were treated surgically mostly using general anaesthesia (95%) and frank pus
obtained in 34 patients(80.95%). The most common organisms obtained on
culture were coagulase-positive staph.aureus and proteus.
Conclusions: Gluteal abscess disease is still common despite advances in
anti-septic techniques. Most of the cases are due to the lack of experience and
improper training of para-medical personnel. This condition is seen more
with certain types of drugs and in immune-compromised patients like
diabetics.

Keywords: Gluteal Abscess, Pattern, Management

INTRODUCTION It is usually related to intra-muscular injections although

other causes has been documented.Intra-muscular
Gluteal abscess is defined as collection of pus in the injections has been used as a means of parenteral drug
subcutaneous plane of the gluteal region. administration for over a century. These injections are
routinely performed by nurses and ancillary staff. The

Mustansiriya Medical Journal Volume 12 Issue 2 December 2013 | 34

 Haqqi I. Razzouki et al.: Management of Gluteal Abscess Disease
incidence of developing a complication from these
injections range from 0.4 to 19.3% 1.Greenblatt et al
found that 46% of hospitalized medical patients
received at least one intra-muscular injection during
their stay[1] .Only 48 of 12134 patients(0.4%) were
reported in this study to have had one of the following
complications: abscess, induration, erythema, wheal
formation, persistent local pain, hematoma, bleeding,
and subcutaneous nodularity1.Pediatric nurses, on the
other hand, report a much higher incidence. Twenty–
three percent of those surveyed had seen a complication
from an injection they had given[2]. Paralysis from
infiltration of the sciatic nerve is an especially dreaded
problem. Other serious complications include fatal gas
gangrene, distal ischemia due to intra-arterial injection
of epinephrine and quadriceps myofibrosis[3].
Other rare complications reported include: scar
formation, muscle fibrosis with contracture of joints,
and very rarely development of malignancy at the site of
injection[1]. The primary factor contributing to most
complications is improper placement of the injection.
The classic placement in the upper outer quadrant of the
gluteal region has fallen out of favor because of hazard
to the sciatic nerve and gluteal vessels if the injection is
too medial to this quadrant[4].
The Swiss anatomist von Hochstetter studied the
problem and concluded that gluteal injections should be
placed in a more lateral triangle bordered by the anterior
superior iliac spine, the tubercle of the iliac crest, and
the upper border of the greater trochanter.
His recommendations have been advocated and
implemented by nursing instructors[5] . A short needle
can also be a problem. Cockshott et al had nurses mark
injection sites on patients before CT of the pelvis. In the
majority of adults, the thickness of gluteal fat was
greater than 3.5 cm[6].
Since Cockshoot et al assumed that most needles were
inserted about 3.0 cm intra-lipomatous instead of
intramuscular injections were the rule rather than the
exception. Such injections are usually more painful,
since the pharmacological agents are more slowly
absorbed. Treadwell suggested that most of the
problems stemming from the procedure are related to
local trauma of the injection itself or the irritating
properties of the drug[7].Many of the complications are
also related to inadequate training in the proper injection
technique [7]
PATIENTS AND METHODS
This is a prospective analytic study. All patients
diagnosed with gluteal abscess and treated at the
surgical wards in Al-Yarmouk Teaching hospital during
Mustansiriya Medical Journal Volume 12 Issue 2 December 2013 |
the period from Oct. the 1st 2011 to April the first 2012
were included in the study.
Relevant demographic data was recorded. The pattern of
clinical presentation was documented including: local
pain, swelling, parasthesia, discharge, fever, chills and
rigors, tachycardia, nausea and vomiting, and backache.
The predisposing factors were documented with special
emphasis on the history of intramuscular injections. The
patients were questioned thoroughly about the details of
these injections including the type of drugs used, the
person who performed the injection, site of injection,
type of syringe, technique of injection and early post-
injection complications.
Other etiological factors like trauma were inquired
about. Relevant medical history like diabetic disease and
other immune-compromising illnesses were recorded.
Besides, surgical history, especially operation for
similar conditions, family history and relevant social
history were documented.
Detailed local clinical examination was done and the
findings recorded on a special chart.
Systemic clinical examination and basic investigations
were done for all patients. For some patients additional
investigations like ultrasonography and CT-scan were
done.
Details of the surgical treatment were documented
including the type of anaesthesia, type of incision, the
findings in detail and the use of drains.
General anesthesia was mostly used. Incision and
drainage of the abscess was the method used in the
surgical management. The type of antibiotics used, in
the pre- and post-operative period, and early post-
operative complications were recorded. Pus drained
during operation was sent for culture and sensitivity.
Post-operatively, intra-venous antibiotics mainly
Ceftriaxone and Metronidazole were used until the
results of culture were obtained. Patients were followed
for one month post-operatively and recurrence or
continuous discharge were observed.
RESULT
Forty – two cases were diagnosed with gluteal
abscess during the period of the study. Thirty were
females (71.42%) and 12 were males (28.57%).Patients
were mainly in the third and sixth decades of life (and
10 patients each). Table-1 shows the demographic data
regarding the gender and the age.
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 Haqqi I. Razzouki et al.: Management of Gluteal Abscess Disease

Table 1: The demographic data The type of drugs used were mainly antibiotics, NSAID
and iron preparations. Fourteen patients (35%) received
Gender
Male Female Cefotaxime, 4(9.52%) received Ceftriaxone and one
NO % NO % each received Ampiclox and Ampicillin. Eight patients
12 25 30 75 received Diclofenac, 4 received iron preparation,
Age
another 2 received steroids and one each received
NO % NO %
0-9 Year 0 0 0 0 Aspegic and a hormonal preparation. In some patients 2
10 – 19 Year 1 2.38 2 11.9 drugs were mixed in the same syringe, mostly
20 – 29 Year 3 7.14 7 16.66 antibiotics and analgesics. In all cases the site of
30 - 39 Year 2 4.76 6 14.28 injection was in the upper outer quadrant of the gluteal
40 – 49 Year 1 2.38 4 9.52
50 – 59 Year 3 7.14 7 16.66
region. Disposable syringes were used in all cases. Table
˃ 60 Year 2 4.76 4 9.52 -4 showed the type of injected drug.

The mean age was 35±1.5.Eighteen patients were Table 4: Type of injected drug
diabetic (42.8%), 16 with type II and 2 with type I. Eight Type of Drug NO %
patients (19.04%) had history of cardio-vascular or
Cefotaxime Na 14 33.3
cerebrovascular disease and 2 (4.7%) had history of Ceftriaxone 4 9.52
deep venous thrombosis. Eight patients were chronic Ampiclox 1 2.38
smokers (19.04%), 16(38.09%) were over-weight and 2 Ampicillin 1 2.38
were morbidly obese (4.7%). Ten patients (23.8%) were Diclofenac 8 19
using steroid preparations, 12(28.57%) were on NSAID, Iron 4 9.52
8 (19.04%) were on aspirin and 4 (10%) were using Steroids 2 4.76
contraceptive pills. Twelve patients (28.57%) had Others 4 9.52
proven anemia, two had leukemia (4.76%) and one had
history of breast cancer (2.38%). The last three patients Injections were done as an outpatient procedure in 19
had received chemotherapy (7.14%) and one had patients (95%) and only two cases were inpatient.
received radiotherapy (2.38%). Table -2 showed the co- Twenty injections were done by a female nurse (49%),
morbid conditions. 8(19%) by a male dresser, 4 by a physician, 4 by a
relative and 2 by the patient himself. Table -5 showed
Table 2: Co-morbid conditions the personnel who is responsible for the injection.
Disease / Condition No % Table 5: Personnel responsible for the injection
Diabetes Mellitus 18 42.8
Cardio –Vascular disease 4 9.5 PERSONNEL NO %

Cerebro- Vascular disease 4 9.5 Male Nurse 8 19

D.V.T History 2 4.76 Female Nurse 20 49

Over –Weight 16 38 Physician 4 9.5

Morbid Obesity 2 4.76 Relative 4 9.5

Chronic Smoker 8 19 Patient 2 4.25

Chronic Steroid 10 23.8

The patient noticed immediate pain or parasthesia in 14
Anemia 12 28.5
instances (33.33%).Three cases of the post-injection
Malignancy 3 7.1
abscess (14%) were recurrent.
Thirty-eight patients (95%) had history of preceding There was history of recurrent or previous perianal
intra-muscular injection. Two patients had history of disease in 6 patients (14.28%).Three of those had fistula
local trauma, one blunt and the other penetrating. The in ano and three had hemorrhoidectomy.Two female
time since the injection episode ranged from 2 days to patients had history of recent gynecological disease.
60 days with a mean duration of 15±3 days. Table -3
showed the etiological factors of gluteal abscess. Clinically, most of the patients presented with pain and
swelling in the gluteal region.
Table 3: Predisposing factors
Forty patients had pain(95.24%) , moderate to severe ,
Cause NO % and 36 patients had visible swelling (85.71%).
Intra-Muscular Injection 38 95
Penetration Trauma 1 2.5 In 18 patient (42.85%) , the mass was fluctuant and in
Blunt Trauma 1 2.5
the other eighteen , the swelling was firm or hard by
Cause Unknown 2 5
palpation. In 6 patients (14.28%), the abscess had
already ruptured by time of presentation. Most of the
Mustansiriya Medical Journal Volume 12 Issue 2 December 2013 | 36
 Haqqi I. Razzouki et al.: Management of Gluteal Abscess Disease
patients had systemic symptoms and signs. Thirty-two
patients had fever (76.19%), 18 (44%) had chills or
rigors, 16 (38%) had tachycardia, 14 (34%) had nausea
or vomiting, 18 (44%) had gait disturbance and 10
(24%) had backache. The duration of the local
symptoms ranged from 2 days to 2 months.
Basic biochemical investigations were done to all
patients. It revealed hyperglycemia in 16 patients (40%),
leucocytosis and raised ESR in 18(44%) and anemia in
16(40%).Ultrasonography was done for 14 patients to
confirm the diagnosis and was positive in all cases.
Eight patients (20%) had received antibiotics without
benefit. Surgery was done to all patients, 38(95%) under
general anesthesia and 4 under local anesthesia because
of cardiovascular disease.Cruciate incision was done in
30 cases (75%) and transverse or elliptical incision in 12
cases. Frank pus was obtained in 34 patients (85%). In 4
patients (7.5%) there was a hematoma with secondary
infection and in another four there was fat necrosis.
Gauze drain was left in the wound in 18 cases (44%),
corrugated drain left in 8 cases (20%) and simple
surgical dressing in 16 cases (36%).In two patients a
foreign body (shell) was found and removed.
All patients received intra-venous antibiotics
postoperatively mainly Ceftriaxone and Metronidazole
until the results of culture were obtained. The patients
remained in hospital from 12 hours to 17 days with a
mean stay of 1+_50 day. All the patients were seen 10
days after discharge from hospital. Six patients (13%)
had recurrence and needed re-operation, 8 had serous
discharge which stopped after conservative treatment
and 28 patients had uneventful recovery. In all patients
pus was sent for culture and sensitivity. The organism
most commonly cultured was coagulase- positive
staphylococcus found in 38 patients (90.47%) and
proteus species in 4 patients (9.53%)
DISCUSSION
Despite the wide use of sterilized disposable needles and
syringes and the use of antiseptic solutions, post-
injection gluteal abscesses continue to occur. Forty-two
patients were diagnosed and treated for gluteal abscess
during the period of the study. Seventy five percent of
these were females. This may be explained by the larger
adipose mass in the gluteal areas in females.The mean
age of those affected was 35± 1.5 years. There was a
clear correlation with immuno-compromised states like
diabetes mellitus with an incidence of 45% mainly type
II.
Also,40% of the patients were over-weight or morbidly
obese. Twenty percent were chronic smokers and 25%
were chronic steroid users. Thirty percent had proven
Mustansiriya Medical Journal Volume 12 Issue 2 December 2013 |
anemia and three patients had malignant disease which
was treated by chemotherapy. Clearly the use of an
intra-muscular injection was the main cause (95%) and
only 4 cases were due to trauma. The duration since
injection ranged from 2 to 60 days. This may be due to
the contaminating bacterial dose, the presence of a
preceding hematoma, any accompanying immuno-
compromised state and the use of antibiotics. Dudley et
al believe that injection abscesses tend to develop slowly
because they start more as an area of necrosis than as a
virulent infection[8].Gradually an indurated mass
develops and eventually over a period of a week or two
an abscess forms[8].
McIvor et al believe that the immunosuppressant effects
of some drugs like steroids may delay the local
inflammatory response[4].
The main drugs responsible were antibiotics, analgesics
and iron. This is to be expected as these are the most
commonly used intra-muscular preparations. However,
there may be some relation to the nature of these drugs.
For example, iron should be injected deeply in the
muscle and by an experienced person, otherwise there is
a high possibility of complications. Cephalosporins and
penicillin derivatives need proper dissolution by
distilled water and if this is not properly done, they will
remain in crystalloid state and cause complications.
AIso, these injections are painful and this may cause the
patient to move during injection or tighten his
muscles[4]. This had been noticed also with analgesics
like Diclofenac and Aspegic. Other drugs mentioned in
the literature include Chloroquine, Epinephrine and
B.C.G vaccine[3]. The classical site of injection was
used in all patients ,so we do not think that this was a
significant factor in the aetiology. The upper outer
quadrant is still considered acceptable despite the
suggestion by Hochstetter[5].
It was not possible to observe the actual process of
injection, however the personal observations of the
authors indicate a wide use of improper techniques of
injection. Although diposable sterile syringes were used
in all patients, however this was not enough to ensure a
perfect anti-septic procedure.
This is related to the experience and training of medical
personnel .Most of the injections were done by nurses
(49%) and dressers (19%) as an outpatient procedure
.The fact that 68% of the patients noticed pain or
parasthesia immediately or very early after injection
indicate the possibility that improper techniques were
the main causes of the abscess. McIvor et al believe that
these abscesses develop due to pathogens carried from
the skin by the needle or seeded hematogenously into an
area injured or made ischemic by the injectate[4]. They
37
 Haqqi I. Razzouki et al.: Management of Gluteal Abscess Disease
also believe that the primary factor contributing to most
complications is improper placement of the injection[4].
In western countries , these abscesses are particularly
prone to occur in drug addicts who self-administer their
drugs[8]. In drug addicts infective thrombophlebitis may
accompany the abscess[8].
In our study, there were two examples of self-
administration. Diabetics also self-administer their
insulin and the lesion may develop in the buttock or
lateral to the iliac crest[8]. Occasionally –but, because
they are usually well trained, uncommonly – a diabetic
will sustain an abscess in the thigh[8]. There was history
of previous or current perianal disease in 29% and this
may facilitate the abscess by making the surrounding
area contaminated and unhealthy. Presence of
gynecological problems like pelvic inflammatory
disease may also play the same role [4].
Clinically, the importance of injection abscesses lies in
their elusiveness and low grade fever may puzzle a
clinician for many days until he carefully examines
injection sites[8].
This is especially true in western countries because the
condition is becoming rarer than before.
The organisms responsible for local necrosis leading for
example to gluteal abscess are mainly staphylococci but
anaerobic strains will do the same[8].
These organisms are associated with rapid rise in tissue
tension often in fascial compartments which contain fat
like the buttock[8].
The result is severe local and sometimes general
symptoms and early necrosis with slough formation.
Dudley et al believe that the tempo of surgical
management must take account of this and, in particular,
the temptation must be resisted to prolong antimicrobial
treatment when what is needed is decompression[8]. The
focus of infection may be in another organ and
transferred hematogenously.. Although staphylococcal
organisms are the main cause in this study and other
studies, other organisms had been mentioned in the
literature. Puthezhath et al reported a case caused by
Mycobacterium tuberculosis[9]. The primary site was in
the spine (Pott's disease).
Another source of T.B. is the abdomen as reported by
Karunakaran[10].
Aligeti et al reported another case caused by Salmonella
typhimurium[11] while Sengupta reported another case
attributed to Entamoeba histolytica[12].
Pyogenic infection with Streptococcus agalactiae is a
potentially life-threatening disease which may present
Mustansiriya Medical Journal Volume 12 Issue 2 December 2013 |
as gluteal abscess complicating dilatation and curettage
for incomplete abortion[13].
Methicillin-resistant community-acquired Staph aureus
had been reported by Dominguez to be responsible for a
cases of gluteal abscess[14] and Bey an et al reported a
case caused by Brucella species[15].
Streptococcus intermedius is related to the milleri group
and is found as a mouth commensal.It was diagnosed as
a cause of gluteal abscess[16].
The organisms obtained after culture in this study were
Staphylococci (90.47%) and Proteus species (9.53%).
The above mentioned organisms were not detected. This
may be explained by the fact that the abscess in this
study is mainly related to improper method of injection
or improper sterilization and not related to a focus of a
disease process in another part of the body.
In many instances, gluteal abscess may be the first
presentation of another important disease process. In the
case reported by Bardhan et al[17], gluteal abscess was
the first manifestation of diverticular disease and the
underlying cause was Crohn's disease as reported by
Hussein et al[18] in which the pus extended through the
fascial planes of the pelvis and through the greater
sciatic foramen into the gluteal area. Perforation of
advanced cecal adenocarcinoma resulted in gluteal
abscess formation as reported by Mohandas[19].
The diagnosis in gluteal abscess is mainly clinical.
Detailed history and a careful clinical examination are
essential. Checking blood sugar and complete blood
count should be done to all patients as there is a high
possibility of hyperglycemia and anemia. In some cases,
ultrasonography and CT scan are needed to confirm the
diagnosis or to exclude accompanying diseases. [9]
The principal management of gluteal abscess is surgical.
General anesthesia is preferred and in many situations
proper muscular relaxation is essential[8].
In our study, general anesthesia was used in 95% of
cases. Aseptic precautions must be as perfect as in a
clean case.Cruciate incision was made in most of the
cases but transverse incision can be used also.
The wound is deepened and all loculi should be broken
down so as to insure that there is one cavity.
It is generally advised that the lining membrane of
granulation tissue should be abraded. After this the
choice lies between complete deroofing, so that drainage
material is needed, and use of a drainage tube.
What appears to be a large cavity and serious cosmetic
blemish usually quickly contracts[8].
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 Haqqi I. Razzouki et al.: Management of Gluteal Abscess Disease
Previously, filling the cavity with gauze was advised but
nowadays this is not acceptable as will interfere with
proper drainage. Tube drainage is generally advised
where there is a deep collection. Counter incision may
be necessary to secure dependent drainage, better still;
the use of negative pressure vacuum drainage will give
better results. Some surgeons recommend primary
suture, In a study by Khanna et, hundred cases of gluteal
injection abscesses were managed by primary closure
technique under antibiotic cover with a tube drain left
in[20].
They claimed a complete healing time of 7-10 days and
reported no recurrence of the abscess and a neat linear
scar. Dudley suggested that this method may be useful
in very early cases[4]. In this study, the patients were
followed for a minimum of 10 days. Twenty-eight
patients (68%) had complete recovery, 8 (19%) had
persistent discharge which healed spontaneously, and 6
(13%) had recurrence for which re-operation in the form
of drainage was needed.The type of drain used didn’t
affect the clinical outcome.
Conclusions
Gluteal abscess disease is still common despite
advances in anti-septic techniques. Most of the cases are
due to the lack of experience and improper training of
Para-medical personnel. Gluteal abscess is seen more
with certain types of drugs (like Cephalosporins and
Diclofenac) and in immune-compromised patients like
diabetics
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