A 50-year-old male comes in to the emergency department complaining of unremitting pain in an area of his right buttock near the anus. Although he is uncertain when the discomfort first began, he notes that the pain has increased significantly over the past 24 hours. He finds he is unable to pass stool because of the pain. He has not experienced symptoms like this before. Ten years ago, he was diagnosed with diabetes mellitus. He is currently on insulin. He smokes half a pack of cigarettes per day but would like to quit. He denies drinking alcohol or using recreational drugs. His temperature is 38.1C (100.6F), blood pressure is 128/86 mm Hg, and pulse is 90/min. There is a hot, tender, mass located between the anus and the left ischial tuberosity. The mass fluctuates upon palpation.
What is the most appropriate next step in the management of this patient?

Question

A 50-year-old male comes in to the emergency department complaining of unremitting pain in an area of his right buttock near the anus.  Although he is uncertain when the discomfort first began, he notes that the pain has increased significantly over the past 24 hours.  He finds he is unable to pass stool because of the pain.  He has not experienced symptoms like this before.  Ten years ago, he was diagnosed with diabetes mellitus.  He is currently on insulin.  He smokes half a pack of cigarettes per day but would like to quit.  He denies drinking alcohol or using recreational drugs.  His temperature is 38.1C (100.6F), blood pressure is 128/86 mm Hg, and pulse is 90/min.  There is a hot, tender, mass located between the anus and the left ischial tuberosity.  The mass fluctuates upon palpation.
What is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: Anal abscesses arise when one or more of the several glands that encircle the anus become blocked and the bacteria within grow unchecked. Patients with anal abscesses typically present with severe, constant pain that may be accompanied by fever or malaise. Physical examination commonly reveals erythematous, indurated skin or a fluctuant mass over the perianal or ischiorectal space. Purulent material may be seen if the abscess has begun to drain spontaneously. It is widely agreed that the most important aspect of treatment is prompt incision and drainage of the abscess (Choice E). Perianal and small ischiorectal abscesses are often drained in the office, but larger ischiorectal abscesses typically require surgical intervention. Increasing the insulin dose (Choice A) or prescribing bupropion (Choice B)are inappropriate because they do not treat the abscess. However, strict control of diabetes is very important in reducing the complications associated with wound healing. Oral antibiotics (Choice C) should also be prescribed to those patients who have diabetes mellitus, immunosuppression, extensive cellulitis, or valvular heart disease. However, antibiotics are an adjunct to and not a substitute for incision and drainage of the abscess. Admission to the hospital for intravenous antibiotics (Choice D) is unnecessary in a patient with localized infection. Educational Objective: Anal abscesses should be treated with prompt incision and drainage. Antibiotics should also be prescribed in those patients who have diabetes mellitus, immunosuppression, extensive cellulitis, or valvular heart disease.

A 50-Year-Old Male Comes in to the Emergency Department Complaining