Anal Fistula and Abscess – Managing Perianal Infections

Q: I am a 16 year old girl. I was recently put on antibiotics by my doctor for a lump under the skin, next to my anus. It started small and it was incredibly itchy, so I thought it was a mosquito bite, but it quickly grew to the size of a strawberry. It was round in shape and under the skin; only a faint redness was visible. It was incredibly painful, and I found it difficult to sit, lie down and walk. I had two more similar lumps before this one, one on my right elbow and one on my left hip, though these were not as big or painful as the one near my anus. All three of these had to be squeezed and huge amount of pus came from them, but they’re now gone.

I was taking antibiotics for a week for the most painful of the lumps. As soon as I finished the antibiotics, four more lumps came up, only small, but all of them around my anus. One is particularly painful. I am worried about how painful it could become having four in the same place. I’m also worried about scars they could leave. Is there something that can stop these lumps from appearing in the first place?

Reply:
You are having these painful lumps again and again. This recurrence of lumps points out that these are not simple boils. There is some underlying disease that needs to be investigated. So just taking antibiotics would not be enough.

Let’s discuss in detail. Painful pus containing lump around the anus is called an anal abscess.

Anal Abscess

An anal abscess is basically an infected cavity filled with pus found near the anus or rectum. There are small glands just underneath the skin of the anus. Sometimes, they get infected by some bacteria, foreign matter or clogging of their small ducts. This leads to the development of an abscess.

Abscess is always treated by draining it. Usually no additional treatment it required.

Predisposing Conditions

If fistula-in-ano are recurrent, they need to be investigated. There are certain conditions which make these infections more likely. They are:

  • Colitis or other inflammatory conditions of the intestine
  • Diarrhea
  • Physical trauma such as a hard stool or foreign body
  • Injury such as a crack (fissure) in the anal tissue
  • Crohn’s disease or ulcerative colitis
  • An immune system that is not functioning well (immunocompromised condition)
  • Tuberculosis
  • Pelvic infections such as diverticulitis or appendicitis
  • Being the receptive partner in anal sex
  • Use of medications such as prednisone
  • Alcoholism
  • Any genitourinary infection
  • An anal fistula

Presence of an anal fistula is the commonest cause of having recurrent perirectal or perianal abscesses in the anal region.

What is an Anal Fistula?

Bowel fistula is the result of a previous abscess. It is a small tunnel that forms under the skin and connects a previously infected anal gland to the skin on the buttocks outside the anus. After an abscess has been drained, the drainage tunnel may persist connecting the anal gland from which the abscess arose to the skin. Persistent drainage from the outside opening may indicate the persistence of this tunnel. If the outside opening of the tunnel heals, recurrent abscess
may develop.

All abscesses do not become fistula-in-ano. There is no way to predict if this will occur.

Management

Get the abscess treated first. Antibiotics are a poor alternative as treatment, because they do not completely penetrate the fluid within an abscess. Proper treatment is always draining the abscess surgically.

An opening is made in the skin near the anus to drain the pus from the infected cavity and thereby relieve the pressure. Often, this can be done in the doctor’s office using a local anesthetic.

Then you need to get investigated for the recurrence of these abscesses.

Presence of any anal fistulas is the first cause to be ruled out.

What About Treatment for a Fistula?

Surgery is done. Although fistula surgery is usually relatively straightforward, the potential for complication exists. So it is preferably performed by a specialist in colon and rectal surgery. It may be performed at the same time as the abscess surgery, although fistulas often develop four to six weeks after an abscess is drained, sometimes even months or years later.

This surgery involves opening up the fistula tunnel. This may require cutting a small portion of the anal sphincter, the muscle that helps to control bowel movements. The external and internal openings of the tunnel are joined. Healing begins from the inside out. Most of the time, fistula surgery can be performed on an outpatient basis, unless it is a deep or extensive fistula.

Treatment of an abscess or fistula is followed by a period of time at home, when soaking the affected area in warm water (sitz bath) is recommended three or four times a day. Stool softeners or a bulk fiber laxative may also be recommended. It may be necessary to wear a gauze pad or mini-pad to prevent the drainage from soiling clothes. Bowel movements will not affect healing.

Measures to Prevent Anal Abscess and Fistula

  • Using stool softeners if constipated. Very hard stools traumatize the anal opening leading to abscess formation.
  • Adding fiber to your diet
  • Drinking plenty of water, up to eight-ounce glasses a day
  • Using clean, moist pads to wipe the area around the anus, to remove any irritating particle or fluid
  • For adults, using condoms during sexual intercourse, including anal intercourse, can help prevent anal abscesses.

Guidelines to keep the lower gastrointestinal tract healthy, hence preventing the occurrence of abscesses:

  • Eat food high in fiber.
  • Drink plenty of water each day (up to 8-ounce glasses).
  • Have regular physical exams to look for underlying diseases of
    the rectum.
  • Have an active lifestyle, with exercises.

Take care

Buddy M.D.

Medical Advice (Q&As) on “Anal Fistula and Abscess – Managing Perianal Infections

  1. Sue

    About six months ago, I had a perineal abscess that had to be surgically drained after it grew to the size of a golf ball in spite of antibiotics. The incision took a long time to heal and even now it feels like sometimes it is leaking air, and is still quite sore. A new abscess seems to have appeared on the opposite side now, and it is a small lump. Yet, it is already quite painful and is located close to the mouth of my vagina. I have been advised to go on a course of Ciplox TZ immediately to see if it helps. The doctors say that if there is a collection of pus it will need to be drained and that recovery may be long and slow. Right now, I have discomfort sitting or clenching and there is a constant pain that travels from my lower back to my legs. I have Crohn’s disease and I usually suffer from alternating diarrhea and constipation and nausea/lack of appetite. What should I do?

    Reply
    1. Buddy M.D. Post author

      It is a rule that collected pus anywhere in the body has to be drained. You may read above about perianal abscess in details.

      Crohn’s disease can be a reason for the recurrence of your problem. You need to take care.

      Reply
  2. Vanessa

    I have Crohn’s disease. I am quite irregular with my medication but I do not have any recurring diarrhea. In fact, I alternate between constipation and diarrhea and it is never severe. I have occasional pain just below the umbilicus but that is rare. What stays is the nausea. I feel very nauseated and pukish all the time, especially at night. I have low appetite and that has reduced the amount of food I eat. That has in turn led to weight loss. I also have an elevated pulse rate (110 per minute) even when I am at rest, but that regularizes if I do breathing exercises. I also feel very fatigued all day and sometimes I feel faint if I am standing. I HAVE to sit down. I also have a lot of joint pain and muscle fatigue all the time. I am a smoker. Could you tell me if I need to make a doctor’s appointment and what could be wrong?

    Reply
  3. Ayesh

    I had a surgery last year, and abscess was drained. It was detected quite early and I healed in the two weeks. This year, however, my previous surgery wound had a bit of swelling. Since I was out of city, I had to meet another surgeon. She said I didn’t have to worry. However, after a week the swelling increased. I had to go to another surgeon and they could not even wait for half an hour because my abscess would have burst. I had my second surgery about 6 weeks ago. When I came back home, my wound was healing nicely. Then there was this pimple sized area that wouldn’t heal and would discharge something white and sticky. It was not puss. Upon the doctor’s visit, I got more medicines. However, right under my wound I had this area that has hardened and hurts when you press on to it. My doctor gave me more medicines but he suspects that a fistula might be there. I have to meet the doctor in a week, but is it possible that I have a fistula without any discharge or constant pain? I donot even have the other symptoms of the fistula. I might go for a pelvic MRI after my doctor’s visit.

    Reply
    1. Buddy M.D. Post author

      Where is the lesion located exactly?

      Yes, you may have a fistula without symptoms. Since it’s recurring, there has to be a source that’s filling it again and again.

      Reply
      1. Anonymous

        The wound area is just on the crack of the left butt cheek. 80% of the wound is on the inside and slight on the buttcheek. The area that hurts is the wall of the butt cheek and the area on the left side of the anus. I have no problems with passing stool though.

        Reply

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