Perianorectal abscess is a purulent disease formed by acute and chronic infection of the soft tissues surrounding the anal canal and rectum. It is characterized by redness, swelling, heat and pain, and is called anal canker sores in Chinese medicine. It is more common in young adults aged 20-40 years old, and is more common in men than women.
Etiology
Western medicine believes that infection is the most important cause of perianal abscess. Other causes such as trauma and tumor can also cause perianal abscess.
1, infection: bad defecation habits, such as long-term constipation or diarrhea patients, can often lead to infection of the anal sinus, with the gradual aggravation of inflammation and purulence, the infection can spread to the soft tissue gap around the anal canal rectum and then form perianal abscess.
Surgery or trauma can lead to damage to the anal area, and if infected, perianal abscesses can also be formed.
2.Tumor: anal canal and rectal tumor breaking infection, smooth muscle tumor in perineal area, powder tumor, lipoma, hemangioma and pre-sacral teratoma, etc., after infection, can develop to the perianal canal and rectal space and form perianal abscess.
3.Other diseases: clonorchiasis, ulcerative colitis, rectal diverticulitis, venereal lymphogranuloma and other diseases can also form perianal abscess if secondary infection occurs. In addition, systemic diseases such as leukemia, diabetes, aplastic anemia and tuberculosis can also form perianal abscesses due to low immunity.
According to Chinese medicine, perianal abscesses mostly occur due to excessive consumption of fat, dry and thick flavors or spicy alcoholic wine or external wind, cold, dryness and fire, dampness and heat injection, meridian obstruction, stagnation of silt and blood, heat and flesh decay.
Clinical manifestations
Perianal abscesses often have local inflammatory manifestations of redness, swelling, heat and pain, which are not difficult to diagnose when combined with systemic symptoms.
Generally, a small hard lump or mass can be found around the anus at the beginning, and with the increase of the mass, pain, swelling and discomfort can occur, which gradually worsens, making it difficult to sit and walk, and even fever, fatigue, loss of appetite, constipation or difficulty in discharging stools, and poor urination. In severe cases, the pain may radiate to the perineum or sacrococcygeal region.
A swollen area around the anus is seen locally, and the skin of superficial abscesses is mostly dark red, while the skin of deep abscesses often does not change color. The local skin temperature is elevated, the pressure pain is obvious, and the fluctuating sensation can be palpated. The soft pus cavity can be palpated in the anal canal or rectum by finger palpation, and there can be pressure pain and fluctuating sensation.
Diagnostic points
According to the different interstices where the abscess is located, it can be divided into the following four types.
1.Subcutaneous abscess: it occurs in the subcutaneous tissue around the anus, with obvious local redness, swelling, heat and pain, and there can be fluctuating sensation by pressure, but the systemic symptoms are not obvious.
2.Sciatorectal fossa abscess: Initially discomfort or slight pain in the anus, gradually aggravated with obvious distension or throbbing pain, difficulty in defecation, and may aggravate the pain, and poor urination. It may be accompanied by fever, chills, loss of appetite and other systemic symptoms. There may be obvious pressure pain or fluctuating sensation on the affected side by anal finger diagnosis.
3.Pelvic rectal interstitial abscess: local symptoms are not obvious, and patients may only have a feeling of rectal cramping or fullness. Systemic symptoms are obvious, and there may be fever, fatigue, loss of appetite and other systemic symptoms.
4.Posterior rectal space abscess: the symptoms are similar to those of rectal space abscess, and there is obvious feeling of swelling in the rectum, and the pain can be radiated to the sacrococcygeal area or lower limbs. Finger palpation can touch pressure, bulge and fluctuating sensation in the posterior rectal wall.
According to the origin of the disease, it can be divided into infectious abscess and tuberculous abscess.
1. Infectious abscess: local redness, swelling, heat and pain, rapid development of the disease, yellow and thick pus with fecal odor after ulceration, accompanied by general discomfort, chills and fever, constipation, short and red urine, yellow and greasy tongue coating and slippery pulse.
2.Tuberculous abscess: local redness, swelling, heat and pain are not obvious, pus formation is slow, pus after ulceration is light white and thin, not smelly or slightly with fecal odor, ulcers are depressed. The whole body is tired and weak, usually without fever or with deficiency fever, with yellow and greasy tongue coating and thin or moist pulse. In case of lung deficiency, coughing and hemoptysis, bone vapor and night sweating may be seen; in case of spleen deficiency, tiredness and dullness, loose stools may be seen.
Physical and chemical examinations: routine blood tests may show elevated white blood cells and neutrophils, especially in deep abscesses. Mycobacterium tuberculosis can be detected in tuberculous abscesses.
Anoscopy: infection of the anal sinus corresponding to the abscess can be seen, and pus can flow from it after pressure.
Endorectal ultrasonography: It is suitable for deep abscesses and can accurately diagnose perianal abscesses and their locations.
[Differential diagnosis
1.Anal skin folliculitis and boils: there is no anal sinus infection and internal opening, the lesion is only in the skin or subcutaneous, and no anal fistula will be formed after penetration.
2.Sacroiliac joint tuberculous cold abscess: long duration, clear history, systemic symptoms, bone changes, inflammation with no pathological relationship with anorectum.
3, pre-sacral teratoma: smaller teratoma, its clinical manifestation is similar to post-rectal gap abscess, finger palpation can palpate a mass behind the rectum, smooth and lobulated, pressure pain is not obvious, cystic feeling. scattered calcification points can be seen on X-ray or ultrasound examination in the rectal cavity.
【Treatment measures
Treatment by community physicians: Once a perianal abscess has formed, ordinary anti-inflammatory effects are not effective, and prompt surgical treatment should be performed.
Internal treatment
(1) Infectious abscess: It is advisable to clear heat and detoxify dampness, using Huanglian Detoxification Tang combined with Gentian and Liver Diarrhea Soup plus or minus.
(2) Tuberculous abscess: It is recommended to nourish yin, clear heat and eliminate dampness, using Artemisia arborescens Tang and Sanmiao Wan plus or minus.
External treatment
(1) Initially: for infected abscesses, apply Jinhuang Paste and Huanglian Paste externally; for tuberculous abscesses, apply Chonghe Paste externally.
(2) Pus formation: When pus has been formed, early incision and drainage is appropriate, but the following surgical methods should be selected according to the depth of the abscess site and the urgency of the disease.
One-time incision method.
For shallow abscesses, the incision should be radial, and the length should be equal to the abscess, so that the drainage is unobstructed.
One-time incision and hanging method.
It is suitable for high abscesses, such as abscesses in the sciatic rectal fossa caused by anal fistula infection, abscesses in the pelvic rectal gap, post-anorectal abscesses and horseshoe abscesses.
Then, the ball probe is used to probe into the abscess incision and gently probe the inner mouth along the bottom of the abscess cavity, and the other index finger is inserted into the anus to guide the search for the inner mouth, and the ball probe is pulled out and tied to the head of the ball with a rubber band thread, and the incision is pulled out through the abscess cavity, and the ends of the thread are gathered and tied, and the wound is filled with red ointment gauze strips, and gauze is applied externally and fixed with wide tape.
Postoperative treatment: apply antibiotics and laxatives as appropriate, use 1:5000 potassium permanganate solution in sitz bath and change medicine after each stool. The hanging threads usually fall off on their own in 10 days, and if they do not fall off after 10 days, the threads can be tightened or cut off as appropriate. However, attention should be paid to whether there is high fever and chills after surgery, and if so, it should be treated promptly.
Staged surgery.
It is suitable for deep abscesses that are frail or unwilling to be treated in hospital. The incision should be made at a site of obvious pressure or fluctuation, as close to the anus as possible, in an arc or radial shape, and must be of sufficient length to keep the drainage open with comfrey oil sand strips. When an anal fistula is formed, it will be treated as an anal fistula. For those with limited inflammation of the lesion and good general condition, if an internal opening is found, the incision and hanging method can be used to avoid secondary surgery, but it must be combined with sufficient amount of antibiotics to control postoperative infection.
(3) After the ulceration: drainage with Jiuyi Dan gauze, pus exhaustion is replaced by gauze of raw muscle. If the fistula is formed over time, it will be treated as anal fistula.
Matters that should be noted during abscess surgery.
(1) Positioning should be accurate: generally puncture should be performed before the abscess is incised and drained, and then incision and drainage should be performed after the pus has been extracted.
Incision: a radial incision is feasible for superficial abscesses, and an arc-shaped incision should be made for deep abscesses to avoid damage to the sphincter.
(2) Drainage should be thorough: after incising the abscess, the abscess cavity should be probed with fingers to separate the fibrous septum in the abscess cavity to facilitate drainage.
(3) Prevent the formation of anal fistula: the primary anal saphenous fossa, the internal opening of the anal fistula, should be incised during surgery, which can prevent the formation of anal fistula.
Home care]
1, the early onset of local hot compress or warm water bath, 2 to 3 times a day, or local physiotherapy (with a spectrum instrument can be shine), can improve blood circulation, promote the absorption of inflammation, reduce pain.
2, oral or injectable antibiotics to control infection.
3.Oral laxative to reduce pain during defecation.
4.The acute inflammation period should be bed rest, if necessary, take painkillers and sedatives such as Valium, ensure sufficient sleep, encourage patients to drink more water, eat more easily digestible, nutritious and fiber-containing food to prevent constipation.
5. If the abscess is mature and fluctuates obviously, the patient should go to the hospital for incision and drainage as early as possible.
Prevention and rehabilitation
1.Cultivate good hygiene habits, bathe and change clothes regularly to keep the perianal area clean.
2.Adhere to the correct method of sitting in the bath regularly when the inflammation first starts.