Management of Abscess Cavities

Introduction to Abscess Management

The World Journal of Emergency Surgery guidelines state that no recommendation can be made regarding the use of packing after drainage of an anorectal abscess based on available literature, representing the most authoritative position on this topic 1
A Cochrane review found that the evidence is weak, concluding it is "unclear whether using internal dressings influences time to healing, wound pain, development of fistulae, or abscess recurrence" 2, 3

Packing is costly, painful, and does not add benefit to the healing process, as concluded by a multi-center observational study of 141 patients 2, 4
The evidence shows packing causes significant pain during dressing changes without therapeutic benefit 5

Instead of xeroform packing, allow the wound to heal by secondary intention without any packing, and instruct patients to begin warm water soaks 24-48 hours after drainage 5
Place a simple catheter or drain into the abscess cavity that drains into an external dressing, and leave in place until drainage stops 2, 4

Complete and adequate drainage at the initial procedure is far more important than any packing strategy, with factors that actually matter for outcomes including inadequate initial drainage, loculations not broken up during initial procedure, horseshoe-type abscess anatomy, and delayed time from disease onset to incision 2, 4, 6
For perianal/perirectal abscesses, make the incision as close to the anal verge as possible, examine for associated fistula tracts during drainage, and perform fistulotomy at time of drainage if low subcutaneous fistula found 1, 4, 6, 7

Remove any initial hemostatic packing within 24 hours, begin warm water soaks 24-48 hours post-procedure, and return immediately for fever, spreading redness, or worsening pain after initial improvement 5

The World Health Organization guidelines suggest that iodoform packing should generally be avoided after abscess drainage, as current evidence demonstrates it causes significantly more pain without improving healing outcomes, recurrence rates, or fistula formation, according to the World Journal of Emergency Surgery 8
A Cochrane review concluded it is "unclear whether using internal dressings influences time to healing, wound pain, development of fistulae, or abscess recurrence", however this information is not directly related to the iodoform packing, but the World Journal of Emergency Surgery provides evidence against it 8

Examining for associated fistula tracts during drainage and performing fistulotomy if a low subcutaneous fistula is found reduces recurrence, as recommended by the World Journal of Emergency Surgery 8, 9

Do not pack routinely "because we've always done it"—this practice lacks evidence and causes unnecessary pain, as stated by the World Journal of Emergency Surgery 8
Do not probe for fistulas if none is obvious, as this causes iatrogenic complications, according to the World Journal of Emergency Surgery 8, 9
Do not prescribe antibiotics routinely for adequately drained abscesses in immunocompetent patients without cellulitis or sepsis, as recommended by the World Journal of Emergency Surgery 9