Acute supralevator abscess: the little we know

Anorectal Abscess

Anorectal abscesses are a common colorectal emergency. The hallmark of treatment is obtaining source control while avoiding injury to the underlying sphincter complex. Understanding the anatomy of an anorectal abscess is critical to planning the appropriate drainage strategy and decreasing the risk of complex fistula formation. Use of antibiotics should be reserved for those with extensive cellulitis, signs of systemic infection, or patients who are immunocompromised. Whether antibiotics prevent future fistula formation is an area of active research. Primary fistulotomy at time of the index drainage is controversial; however, there may be situations where it is appropriate. It is important to counsel patients that after effective drainage of an anorectal abscess, they have a 30 to 50% chance of developing an anal fistula that will then require further treatment.

Delayed diagnosis of perirectal horseshoe abscess and patient's perspective

This is a case of a woman in her 50s with HIV and uncontrolled diabetes who presented to the emergency department with urinary retention and a painful gluteal cleft lesion, admitted for cellulitis. Since initial CT and soft tissue ultrasound (US) were negative for fluid collection, the care team was surprised to find her symptoms continued to progress despite intravenous antibiotics. Finally, MRI 9 days into her admission demonstrated a 12-cm perirectal horseshoe abscess. The patient was ultimately treated with incision and drainage with Penrose drain placement. This case demonstrates the importance of maintaining a high suspicion for horseshoe abscess, a complex form of ischiorectal fossa abscess which can be missed on CT and US imaging, and which may expand rapidly in immunosuppressed patients.

Perineal sepsis and successful surgical treatment in supralevator and ischiorectal fossa abscess: a case report

A male 61-year-old patient presented to the emergency department with fever, leukocytosis and perineal pain. Macroscopic examination of anogluteal region demonstrated a bulky inflamed mass in the left ischiorectal fossa with a skin defect draining large amounts of pus. The suprapubic area was observed to be erythematous, with local tenderness and a palpable inflammatory mass under the skin. Computed tomography and magnetic resonance imaging revealed an abscess of the ischiorectal fossa and concomitant supralevator abscess. Examination under anesthesia revealed an internal fistula at the posterior dentate line, with pus emanating from the orifice. A bulging mass was found, protruding in the left lateral and inferior area of the rectal ampulla, a finding compatible with the supralevator abscess identified by imaging. Drainage of the abscess into ischiorectal fossa, supralevator space and suprapubic area was successful with a prompt improvement in the clinical and laboratory profile of the patient.