Anorectal Abscess in Children

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Anorectal (perianal or perirectal) abscess is a relatively common condition in children. It occurs most often in male infants younger than 1 year but can occur in either sex and at any age. The exact incidence and prevalence are not well established. The treatment approach varies somewhat by age and, in most instances, differs from that used in adults (see Anorectal Abscess).

A perianal abscess is an infection characterized by a collection of pus that has formed under the skin within the soft tissue just outside the anus. The abscess often appears as a raised red lesion under the skin lateral to the anus, where it may grow and become painful. Some abscesses spontaneously drain pus and heal; others require surgical intervention. Some perianal abscesses heal incompletely, with or without surgery, leaving a tiny opening at the site of drainage (anal fistula, or fistula-in-ano), which may or may not require additional surgery.

The vast majority of anorectal abscesses develop spontaneously in completely healthy children and are self-limited; however, in older children, the condition can be associated with inflammatory bowel disease (IBD) or other conditions in which the immune system is compromised.

Controversies abound in the treatment of perianal and perirectal abscesses (see Treatment). The use of antibiotics alone (rather than surgical drainage) as a means of definitive treatment with the intention of decreasing the likelihood of eventual fistula-in-ano formation is quite controversial but is supported in the literature. [1] Nonoperative management of fistula-in-ano via observation alone in otherwise completely healthy male babies remains controversial but is also supported in the literature. [2]

The anal canal and the skin around it are the site of perianal abscesses and fistulas. Just inside the anal canal, about 1-2 cm from the anal verge in most babies, are small pits in the wall of the anal canal called anal crypts (or the crypts of Morgagni). It is believed that anorectal abscesses and fistulas originate as an infection in these anal crypts. The infection then erodes through the wall of the anal canal and extends into the fat beneath the perianal skin. From here, it can continue in one of two directions, as follows:

The pathophysiology and etiology of anorectal abscess and fistula-in-ano have not yet been fully defined. The prevailing theory is that an infection in an anal crypt, or crypt of Morgagni—that is, cryptitis—progresses and erodes through the wall of the anal canal into the surrounding soft tissue, where a collection of pus accumulates, forming the abscess.

When an anorectal abscess drains spontaneously by eroding through the skin or is surgically drained, a communication is formed between the abscess cavity and the skin. If the infection truly originates from an anal crypt, the abscess cavity must communicate with the lumen of the anal canal. The hole in the skin would therefore also communicate all the way into the anal lumen. When this communication persists over several weeks, it is called a fistula. It is unclear why fistulas form in some individuals but not in others. [1]

If the etiology of fistula is abscess drainage, either spontaneously or through surgical incision, it logically follows that efforts to cure the abscess before it drains, thereby avoiding completing the communication from the anal canal to the skin, may decrease the risk of fistulization. Various studies have followed this line of thinking (see Treatment).

Some authors have suggested that some infants have abnormal crypts, which predispose them to cryptitis and abscess formation. One study showed that the anal crypts of infants with fistulas tend to be deeper (3-10 mm) than those of healthy infants (1-2 mm). [3] It has been proposed that androgen excess or androgen-estrogen imbalance may predispose to the formation of these abnormal crypts. [4]

The overall incidence of anorectal abscesses in children is unknown. It is a relatively common condition seen in a general pediatric or pediatric surgical practice. In infants, the pediatric subgroup among whom this condition is most prevalent, the estimated incidence is between 0.5% and 4.3%, with an overwhelming male preponderance. In older children, anorectal abscesses show no sexual predilection. No racial predilection is reported in any age group.

The prognosis of anorectal abscess in children is excellent for all cases that are unrelated to Crohn disease. With or without surgery, the condition will eventually be brought to a successful resolution with no impact or implications for the future.

Children with abscesses who undergo drainage are likely to develop a fistula. Fistulas in children usually resolve without intervention, but some patients require surgery for resolution. Treatment of any concomitant fistula may enhance the results of surgical treatment of first-time perianal abscesses in children. [5] Recurrent fistula after fistulotomy in an otherwise healthy child is very unlikely and should prompt an evaluation for other disease processes (eg, chronic granulomatous disesase or Crohn disease).

The prognosis of Crohn-related perianal pathology is complex and beyond the scope of this article.

Christison-Lagay ER, Hall JF, Wales PW, Bailey K, Terluk A, Goldstein AM, et al. Nonoperative management of perianal abscess in infants is associated with decreased risk for fistula formation. Pediatrics. 2007 Sep. 120 (3):e548-52. [Medline]. [Full Text].

Rosen NG, Gibbs DL, Soffer SZ, Hong A, Sher M, Peña A. The nonoperative management of fistula-in-ano. J Pediatr Surg. 2000 Jun. 35 (6):938-9. [Medline].

Shafer AD, McGlone TP, Flanagan RA. Abnormal crypts of Morgagni: the cause of perianal abscess and fistula-in-ano. J Pediatr Surg. 1987 Mar. 22 (3):203-4. [Medline].

Fitzgerald RJ, Harding B, Ryan W. Fistula-in-ano in childhood: a congenital etiology. J Pediatr Surg. 1985 Feb. 20 (1):80-1. [Medline].

Juth Karlsson A, Salö M, Stenström P. Outcomes of Various Interventions for First-Time Perianal Abscesses in Children. Biomed Res Int. 2016. 2016:9712854. [Medline]. [Full Text].

Chang HK, Ryu JG, Oh JT. Clinical characteristics and treatment of perianal abscess and fistula-in-ano in infants. J Pediatr Surg. 2010 Sep. 45 (9):1832-6. [Medline].

Afşarlar CE, Karaman A, Tanır G, Karaman I, Yılmaz E, Erdoğan D, et al. Perianal abscess and fistula-in-ano in children: clinical characteristic, management and outcome. Pediatr Surg Int. 2011 Oct. 27 (10):1063-8. [Medline].

O’Riordan JM, Datta I, Johnston C, Baxter NN. A systematic review of the anal fistula plug for patients with Crohn’s and non-Crohn’s related fistula-in-ano. Dis Colon Rectum. 2012 Mar. 55 (3):351-8. [Medline].

Nelson G Rosen, MD, FACS, FAAP Assistant Professor of Surgery and Pediatrics, Albert Einstein College of Medicine; Attending Pediatric Surgeon and Director, Pediatric Trauma Center, Department of Pediatric General Surgery, Schneider Children’s Hospital

Nelson G Rosen, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, American Trauma Society, Association of Military Surgeons of the US, Eastern Association for the Surgery of Trauma, Canadian Association of Pediatric Surgeons

Disclosure: Nothing to disclose.

Robert K Minkes, MD, PhD Medical Director of Pediatric Surgical Services, Golisano Children’s Hospital of Southwest Florida; Lee Physicians Group

Robert K Minkes, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Asma Al Mannaie, MBBS Acting Chair of Health Education Section, Department of Preventive Medicine, Sheikh Khalifa Medical City

Disclosure: Nothing to disclose.

Andre Hebra, MD Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine; Surgeon-in-Chief, Medical University of South Carolina Children’s Hospital

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Children’s Oncology Group, Florida Medical Association, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons,South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

Pramod S Puligandla, MD, MSc, FRCSC Assistant Professor, Departments of Surgery and Pediatrics, Divisions of Pediatric Surgery and Pediatric Critical Care, McGill University Health Centre; Consulting Staff, Montreal Children’s Hospital/Research Institute

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.


The author wishes to acknowledge two eminent pediatric surgeons, Dr Alberto Pena (the author’s mentor) and the late Dr James Warden. On a visit to his friend Dr Pena, Dr Warden communicated his technique of nonoperative management of fistula-in-ano. This radical concept led to a study of this approach in which the author extensively participated and thereby inherited Dr Pena’s passion for this subject and for the optimal care of children with this condition.

The author would also like to thank Dr Peter Masiakos and his colleagues for their further efforts to advance the nonoperative treatment of children with perianal abscess with the conviction that avoiding fistula-in-ano is better than treating it.

Anorectal Abscess in Children

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