Perianal Abscess and Fistula


How is perianal abscess and fistula-in-ano different in children compared to adults?

The presentation and management of perianal abscess and fistula-in-ano typifies the adage that “children are not just little adults.” Adults with perianal abscess often present with significant pain and signs of systemic sepsis. Successful treatment necessitates prompt surgical drainage and patients who develop fistula-in-ano often struggle with chronically draining tracts that rarely close spontaneously [1][2][3].

Perianal abscess and fistula-in-ano in children is typically a much more benign disease - especially among infants [4][5][6]. Most patients who present with perianal abscess are otherwise healthy with no signs of systemic sepsis. Surgical drainage may not be required and many clinicians avoid antibiotics as well. The possibility of Crohn disease should be considered in older children and adolescents [7]. Similarly, immunocompromised children of any age may develop perianal abscess and require more aggressive medical and surgical management.

Children with fistula-in-ano who are otherwise healthy may experience spontaneous closure and resolution [4][6]. These tracts tend to be more superficial and simple than those found in adults since they do not typically involve the sphincter complex [8]. Children with fistulas that do not heal spontaneously can almost always be treated by simple fistulotomy. Seton sutures are not required in patients who do not have Crohn disease. Similarly, complex repairs such as mucosal advancement flaps, fibrin glue injection and the ligation of intersphincteric fistula tract (LIFT) procedure are also not necessary in the pediatric population. The rationale for using these techniques in adults is to preserve the integrity of the sphincter complex. This is rarely a concern in children since the fistula tracts are low and heal spontaneously or with simple fistulotomy.

content in this topic is referenced in SCORE Anal Pathology: Fissures, Abscesses, Fistulae, Pilonidal, Prolapse overview

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Last updated: November 2, 2020