Management of intersphincteric abscesses

Abstract

Low intersphincteric abscesses should be treated by de-roofing of the abscess and division of the internal sphincter up to a level of the dentate line. High intersphincteric abscesses are relatively frequent and mostly require staged surgery with a temporary mushroom (de Pezzer) catheter. Accurate anatomical ultrasound localization and proper drainage become important to avoid recurrences or extrasphincteric fistulas.

Ultrasonographic assessment of patients referred with chronic anal pain to a tertiary referral centre

“…In our series, all patients had previously sought consultant help without a definitive diagnosis having been made over a prolonged period of time, where the diagnosis of primary ISS was relatively common. This data would suggest that ISS as a clinical diagnosis is not rare as has been previously suggested [10] and some cases of with functional anorectal disorders will be misclassified without dedicated imaging [23]. The difficulties in diagnosis of ISS, which represents between 5 and 25% of all anorectal abscesses [24], are because the protean external clinical signs of swelling or perianal induration may be absent and where the likelihood of ISS as a principal diagnosis increases in recurrent septic cases following prior inadequate drainage [25].…”

“…Some have argued on this basis that anorectal morphological investigation is unwarranted in this group of patients because of its low yield [6,7]. Against this, it is well recognized that deep-seated perirectal sepsis may be occult, particularly in the postoperative patient [8,9] and although uncommon, a primary intersphincteric abscess may present with chronic anal discomfort, being both difficult to manage successfully [10], requiring specialized anal imaging [11,12] or even examination under general anaesthesia [13]. It is vital that this diagnosis is made by the referred clinician since recently, successful management in selected cases has been described using endosonographic drainage [14].…”

Cryptoglandular anal fistula

“…They occur mainly in high fistulas, after ill-advised antibiotic and/or steroidal treatment, in cases of Crohn's disease, or after previous surgical interventions. Diverticula can extend into the intramural space, more rarely into the supralevator space, and occasionally into the upper pelvirectal space [12,13]. They may also extend across to the opposite side, forming a horseshoe extension.…”

Hallazgos en endosonografía anorrectal en una cohorte prospectiva

“…Existe un grupo importante de pacientes cuya endosonografía fue reportada como normal con indicaciones diversas, donde se destaca el diagnóstico mayoritario de proctalgia; incluso dentro del grupo al que se le indicó este estudio por proctalgia, el 33% reportó un examen normal, lo cual está en congruencia con lo reportado en la literatura mundial (23)(24)(25)(26).…”

“…Las medidas de los esfínteres están reportadas como normales en la gran mayoría de los casos, pero esto está influenciado porque dichas medidas se realizan a las "9" y "3" del reloj (aspecto lateral de los esfínteres), lo cual dista de la presencia de las alteraciones encontradas en las endosonografías por incontinencia, por ejemplo, que son en nivel anterior, y esta es la indicación más frecuente (24)(25)(26)(27).…”