Anal Fistulas and Abscesses: Surgical Insights and Management

Anal fistula? Anal abscess? And preoperative management of abscess issues?

Recently, during a bout of constipation in the cold winter, I accidentally splashed some water onto my anus while straining.
Two hours later, I noticed a small red and swollen area next to my anus.
After 1 to 3 days, the swelling increased slightly, and the pain intensified.
By the fourth day, the pain disappeared, but the swollen area grew larger and began to ooze pus.
Upon inspection in the mirror, it appeared to be about 1.5 cm high and 0.5 to 0.7 cm wide.
Currently, there is no pain when I apply pressure to the internal area of the anus or the swollen area; it does not hurt even when I touch the swollen area lightly.
The pus continues to ooze intermittently, and my bowel movements are normal without any discomfort affecting my rectum.
I consulted a colorectal surgeon who looked at it for about ten seconds and said, "This is an anal fistula with pus; it will be fine to let it drain on its own, and surgery is not immediately necessary, but it would be best to have surgery within ten years." I was prescribed antibiotics for three days.
After thinking it over, I expressed my desire for surgery, but the doctor said, "We will reassess the wound in a month (36 days later) to schedule the surgery; you should be able to go home the same day." I find the one-month wait quite strange, so I googled it and found that delaying treatment for an inflamed fistula could lead to recurrent inflammation and complications.
I also learned that only about 50% of anal abscesses develop into fistulas, and treatment for anal abscesses typically involves antibiotics and incision for drainage.
1.
Why do I have to wait a month to reassess the wound before scheduling surgery? I found many sources online that do not mention waiting this long.
Is this an observation period for the anal abscess to fistula? Why was there no incision for drainage?
2.
How should I manage the intermittent pus drainage now? (Currently, I am using a sanitary napkin in my underwear, changing it every half hour to gently press and absorb the pus 1 to 2 times, discarding it afterward, and washing with warm water 2 to 3 times a day.)
3.
Can sitz baths or using a heating pad on my buttocks improve my current condition? (Most information I found pertains to post-operative care.)
4.
How should I manage this swollen area over the next month?
5.
Should I schedule another appointment? When should I return to the doctor for a follow-up? (If the pus stops draining.)
6.
Under what circumstances can I consider having surgery sooner? (If the pus stops draining? If the abscess shrinks?)

Mr. Yu, 20~29 year old female. Ask Date: 2016/02/01

Dr. Ke Fangxu reply Surgery

1.
It is reasonable to observe for one month before deciding whether to proceed with surgery, as an anal abscess can completely heal without developing into an anal fistula.
The reason for not performing incision and drainage is that your anal abscess has already ruptured on its own, so further incision is unnecessary.

2.
The discharge of pus may last for about 3-5 days.
It is generally recommended to use sanitary pads for better absorption, and frequent warm sitz baths can help keep the wound clean and promote healing.

3.
It is better to avoid using an electric heater to warm the area to prevent accidental burns; the water temperature for sitz baths should also not be too hot.

4.
You can apply topical ointments for hemorrhoids, which will have anti-inflammatory and astringent effects.

5.
If there is no persistent pain or discharge, you can wait for one month and then have a doctor check for the presence of an anal fistula.

6.
If the abscess expands and medication is ineffective, surgical intervention may be necessary sooner.

Reply Date: 2016/02/01

More Info

Understanding anal fistulas and abscesses is crucial for effective management and treatment. Based on your description, it seems you are experiencing symptoms consistent with an anal abscess that may lead to a fistula. Here’s a comprehensive overview of your situation, addressing your concerns and providing insights into the management of anal fistulas and abscesses.

1. Why Wait a Month for Surgery?
The decision to wait a month before considering surgery is likely based on the physician's assessment of your condition. In some cases, if an abscess is not causing severe symptoms or complications, doctors may opt for a conservative approach, allowing the body time to heal naturally. However, this can be a double-edged sword. While some abscesses may resolve on their own, others can develop into chronic conditions, such as fistulas, if not addressed promptly.
Your doctor may be monitoring the situation to see if the abscess resolves or if it develops into a fistula. It’s important to communicate your concerns about the potential for complications, as you mentioned that only about 50% of anal abscesses may lead to fistulas. If you feel that your symptoms are worsening or not improving, it is reasonable to seek a second opinion or request an earlier follow-up.

2. Managing Continuous Pus Drainage
The continuous drainage of pus indicates that the abscess is still active. Keeping the area clean is essential to prevent further infection. Your current method of using sanitary pads and cleaning with warm water is appropriate. However, you should also consider the following:
- Keep the area dry: After cleaning, ensure the area is dry to prevent moisture buildup, which can promote bacterial growth.

- Avoid irritants: Use gentle, unscented soaps and avoid any harsh chemicals or wipes that could irritate the area.

- Monitor for changes: Keep an eye on the color, consistency, and amount of pus. If you notice any changes, such as increased redness, swelling, or fever, seek medical attention promptly.

3. Benefits of Warm Sitz Baths
Warm sitz baths can be beneficial for managing discomfort and promoting healing in the anal region. They can help:
- Reduce pain and swelling: The warmth can soothe the area and improve blood circulation, which may aid in healing.

- Promote drainage: Warm water can help soften the area, potentially facilitating drainage of pus.

You can take sitz baths several times a day, especially after bowel movements, to keep the area clean and comfortable.

4. Managing the Swelling
For the swollen area, continue with your current care regimen. If the swelling persists or worsens, it may indicate that the abscess is not resolving. In such cases, it’s crucial to follow up with your healthcare provider sooner rather than later.

5. When to Revisit the Doctor
If the pus drainage stops and the swelling decreases, you may not need to see the doctor immediately. However, if you experience any of the following, you should seek medical attention:
- Increased pain or discomfort
- Fever or chills
- Changes in bowel habits
- Persistent swelling or drainage

6. Timing for Surgery
The decision to proceed with surgery should be based on the clinical evaluation of the abscess and any associated symptoms. If the abscess does not resolve within a reasonable timeframe or if it begins to form a fistula, earlier surgical intervention may be warranted. Generally, surgery is considered when:
- The abscess is not improving with conservative management.

- There are signs of a fistula developing.

- You experience significant discomfort or complications.

In conclusion, while waiting for surgery may seem concerning, it is essential to maintain open communication with your healthcare provider about your symptoms and any changes you observe. If you feel uncomfortable with the current plan, do not hesitate to seek a second opinion or request a more immediate evaluation. Your health and comfort are paramount, and proactive management is key to preventing complications associated with anal abscesses and fistulas.

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