Incision and Drainage of Abscesses: Recommended Treatment Approach

General Principles of Abscess Management

The primary recommended treatment for abscesses is surgical incision and drainage, with timing dictated by the severity of sepsis and patient comorbidities 1, 2
Surgical drainage is the cornerstone of abscess management, regardless of location 1, 3
The incision should be kept as close as possible to the anal verge for perianal abscesses to minimize potential fistula length while ensuring adequate drainage and avoiding sphincter damage 1
Complete drainage is essential, as inadequate drainage is associated with high recurrence rates (up to 44%) 2, 4
Incision and drainage is superior to needle aspiration, with recurrence rates of 15% vs 41% respectively 2

Emergency drainage is indicated for patients with sepsis, severe sepsis, or septic shock 5
Emergency drainage is also indicated for patients with immunosuppression 5
Emergency drainage is indicated for patients with diabetes mellitus 1
Emergency drainage is indicated for patients with diffuse cellulitis 2, 6
In the absence of these factors, surgical drainage should ideally be performed within 24 hours 2

Perianal and ischioanal abscesses: Incision and drainage via the overlying skin 2
Intersphincteric abscesses: Drainage into the rectal lumen, possibly with limited internal sphincterotomy 2, 6
Supralevator abscesses: Drainage via rectal lumen (if extension of intersphincteric abscess) or externally via skin (if extension of ischioanal abscess) 2

Young, fit patients without signs of sepsis may have surgery in an ambulatory setting 2
Outpatient management can be considered for immunocompetent patients with small perianal abscesses without systemic signs of sepsis 1, 2

The role of wound packing after abscess drainage remains controversial, with some evidence suggesting that packing may be necessary for hemostasis and to prevent premature skin closure 2, 5

Risk factors for abscess recurrence include loculations 2, horseshoe-type abscess 1, and delayed time from disease onset to incision 2, 4
Routine imaging after incision and drainage is not required, but follow-up imaging is suggested in cases of recurrence 5, suspected inflammatory bowel disease 4, or evidence of fistula or non-healing wound 1, 3