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Case 168: Not again

A 47 year old man presents with a very painful left buttock. He says this has happened two times before and each time he required surgery.

1. Describe the problem seen in the photo?

There is a large left sided ischiorectal abscess. Cellulitis is spreading from this septic source across most of the left buttock. The pus is pointing laterally at about 4 cm's from the anal verge in the 3 O'Clock position. The skin in this area is becoming necrotic.

2. What would be your management?

Drainage of the collection under a general anaesthetic through the area of compromised skin. A mushroom catheter placed into the cavity will decrease the incidence of abscess reaccumulation, which can be as high as 10%.

The chance of there being an internal opening is high with the prior episodes, however this may not be able to be found with probing in the acute situation. Overly aggressive attempts to find one may create a false passage leaving the patient with an iatrogenic fistula.