Anal Abscesses: Symptoms, Diagnosis, and Treatment Options

There is an anal abscess. No internal opening present?

Hello Dr.
Ke,
On December 9th, I noticed mild swelling at the 7 o'clock position of my anus and applied a topical ointment.
On December 10th, the swelling became somewhat painful, so I applied the ointment again and took SP002 (1) and ST474 (1).
On the morning of December 11th, I developed a painful abscess that felt soft to the touch, making it difficult to sit.
I soaked in warm water for 15 minutes and applied the ointment again with SP002 (1) and ST474 (1).

On the evening of December 11th at 11:00 PM, the pain intensified with slight itching.
I took a photo with my phone and noticed three small openings on the abscess oozing white pus.
On December 12th at 12:10 AM, the pain and itching were severe, and the abscess ruptured, releasing white pus mixed with a small amount of blood.
After squeezing it, I applied iodine and the ointment again with SP002 (1) and ST474 (1).

By December 14th, I could walk and sit without pain, but there was slight tenderness upon pressure, and I could vaguely feel a tubular structure.
On December 15th, I visited a colorectal surgeon who performed a digital examination and anoscopy.
He indicated that there was an anal abscess at the 7 o'clock position without an internal opening and suggested a 90% chance of an anal fistula.
The doctor asked if I wanted to proceed with surgery.

I would like to ask Dr.
Ke: Is it not true that a fistula should have an internal opening? The doctor’s 90% likelihood of a fistula means that the remaining 10% might not be a fistula, which could lead to unnecessary surgery.
If I choose to observe further, could a simple fistula evolve into a complex one, which would be more troublesome? Besides the digital examination and anoscopy, is it possible to use imaging techniques (like X-rays or MRI) to confirm the presence of a fistula?
I appreciate your time and look forward to your response.
Thank you!

Vivian Hsu, 50~59 year old female. Ask Date: 2023/12/17

Dr. Ke Fangxu reply Surgery

Based on your description, it seems that the anal abscess has ruptured on its own.
If this is the first occurrence of such an event, I would generally recommend observing for a period of time before deciding whether to undergo surgery.
An anal fistula is a complication that can arise after an abscess.
During the abscess stage, the internal opening of the fistula may not be visible; it is only during the fistula stage that a simple fistula can be identified.
A simple fistula does not evolve into a complex fistula in a short time; it requires a process of repeated infections to become complicated.
I suggest discussing this thoroughly with your physician before deciding on the next steps in treatment.

Reply Date: 2023/12/17

More Info

Anal abscesses are localized collections of pus that occur near the anus, often resulting from an infection in the anal glands. They can cause significant discomfort and may lead to complications if not treated appropriately. Based on your description, it seems you are experiencing symptoms consistent with an anal abscess, which has progressed to a point where it has ruptured and drained.

Symptoms of Anal Abscesses
The symptoms of an anal abscess typically include:
- Pain and swelling around the anus
- Tenderness when sitting or moving
- Fever or chills in some cases
- A visible lump or swelling near the anus
- Drainage of pus or blood, especially if the abscess ruptures
In your case, the progression from mild swelling to significant pain and the eventual rupture of the abscess aligns with typical presentations. The presence of a "soft" area that is painful to touch and the subsequent drainage of pus are key indicators of an abscess.

Diagnosis
Diagnosis of an anal abscess is primarily clinical, based on the history and physical examination. The doctor may perform a digital rectal examination and possibly an anoscopy to assess the area. In some cases, imaging studies such as ultrasound or MRI can be used to evaluate the extent of the abscess and to check for any associated fistulas (abnormal connections between the anal canal and the skin).

Treatment Options
The standard treatment for an anal abscess involves:
1. Incision and Drainage (I&D): This is the most common and effective treatment. The abscess is surgically opened, and the pus is drained. This procedure can often be done in an outpatient setting.

2. Antibiotics: While not always necessary, antibiotics may be prescribed, especially if there are signs of systemic infection (fever, chills).

3. Fistula Management: If a fistula is present or develops, further surgical intervention may be required to ensure proper healing and to prevent recurrence.

Concerns About Fistulas
You raised a valid concern regarding the potential for a fistula. While it is true that many anal abscesses can lead to the formation of a fistula, not all do. The statement that there is a 90% chance of a fistula being present is based on statistical observations, but it does not guarantee that every case will result in one. If you choose to observe rather than proceed with surgery, there is a risk that the abscess could recur or that a fistula could develop, which might complicate future treatment.

Imaging Studies
Regarding your question about imaging, while a physical examination is often sufficient for diagnosis, imaging studies like an MRI can provide additional information about the presence of a fistula and the extent of the infection. An MRI is particularly useful in complex cases where the anatomy is not clear or when there is a suspicion of deeper infection.

Conclusion
In summary, it is crucial to address an anal abscess promptly to avoid complications. If your doctor has recommended surgery, it is likely based on the clinical findings and the risk of complications. If you have concerns about the necessity of surgery or the possibility of a fistula, it is reasonable to seek a second opinion or discuss further imaging options with your healthcare provider. Ultimately, the goal is to ensure complete resolution of the abscess and to prevent any future complications.

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