Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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370 Surgery and Healing in the Developing World
Figure 16. Unroofed ischiorectal
abscess.
Perianal/Perineal
Superficial abscesses and boils are common in this region and require local drainage
only. Recurrent boils may indicate an underlying condition such as diabetes mellitus.
Deeper infections are potentially dangerous and must be diagnosed early and
treated aggressively.
Ischiorectal Abscess
These abscesses occur in the deep fat of the ischiorectal space. The patient may
give a history of pain on defecation followed by increasing pain and swelling, usually
at one side of the anus. Tenderness becomes so severe that the patient is unable to sit
comfortably and even walking is painful. Examination reveals a tender hot mass
which may or may not be red. The above symptoms and signs are sufficient to
indicate incision and drainage of the abscess. Fluctuance is a late sign and surgical
drainage should not await fluctuance in this region. Drainage can be provided under
local anesthesia, injecting 0.5% tetracaine liberally along the line of incision and
widely in the fat over the abscess. However, general anesthesia provides more comfort
for patient and surgeon in the exposure and drainage of all loculi and cavities.
The surest approach is to do a wide incision unroofing the entire abscess. Removal
of an ellipse of skin helps keep the cavity open (Fig. 16). The cavity is then packed
loosely with a single piece of sterile gauze. (Insertion of more than one piece of gauze
into a large abscess sometimes results a piece of gauze inadvertently being left in the
wound.) The large gaping wound will take several weeks to heal but leave a surprisingly
small scar. Some experienced surgeons may opt, in defined circumstances, for
a smaller incision and insertion of a drain. This latter approach facilitates early discharge
home and may avoid admission to hospital, but it may also lead to inadequate
drainage and recurrence of the abscess. Intravenous antibiotics should be
administered immediately prior to drainage to minimize the risks of bacteremia
associated with the procedure. Cultures of the pus should not be affected by this.
Choose antibiotics, such as chloromycetin or a combination of gentamicin and flagyl,
to cover aerobic and anaerobic gut organisms. In every case, the patient should be
advised that a fistula-in-ano may develop later.
Perineal Abscess
Perineal abscess may be a variant of ischiorectal abscess located anterior to the
anus. It may also, in males, be due to trauma to the urethra or impacted urethral
calculi. Gonnorrhea or tuberculosis may produce perineal abscesses. Drainage should
be as for ischiorectal abscesses.