Published online August 31, 2007
PEDIATRICS Vol. 120 No. 3 September 2007, pp. 646 (doi:10.1542/peds.2007-1295)

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COMMENTARY

Surgeons Say No to Surgery for Perianal Abscesses in Infants

Myles B. Abbott, MD, FAAP

East Bay Pediatrics, Berkeley, California

Who would ever imagine surgeons stating the heretical view that an abscess does not need to be drained? Yet, that is the recommendation of the surgeons who wrote an article on the management of perianal abscesses for this month's Pediatrics Electronic Pages.¹ Although this condition has generated controversy for a long time,² perianal abscesses traditionally have been treated surgically by incision and drainage. On the basis of a 10-year retrospective analysis of hospital records, this provocative study contradicts that approach. The authors showed that medical management is superior to surgical treatment, because it takes care of the immediate problem as effectively as surgical intervention but with a lower risk of fistula-in-ano resulting.

In general pediatric practice, perianal abscess is uncommon but not rare. Because it usually does not cause systemic symptoms, the condition most often presents in the pediatric ambulatory setting rather than the emergency department. The infant (most often a male infant) appears healthy, is afebrile, and has little or no discomfort. Typically, a parent will inquire about a mass near the child's anus, or the physician will find it on a routine examination. Once the abscess is identified, the pediatrician has to decide whether to manage the child medically or surgically.

Although the Christison-Lagay et al¹ study is persuasive, it has multiple limitations. It was retrospective. The size of the abscess on admission was not recorded and could have affected decisions about initial management (larger abscesses would be drained, smaller ones would be watched). Moreover, because the patients in their study were all seen in a hospital setting after surgical referral, it is possible that many smaller perianal abscesses that did not arouse concern in the parent or pediatrician were treated medically without surgical consultations or were surgically managed by the primary care provider using incision and drainage or needle aspiration. Also, the authors hypothesized that the male predominance of this disorder is secondary to the higher surge of testosterone that previous studies have noted in boys versus girls during the first few months of life. However, this theory was not substantiated in their study, because testosterone levels were not measured in these infants; even if the levels were elevated, that would not prove a direct causal relationship.

Despite these limitations, it is reasonable to try medical management before resorting to surgical intervention for an infant with a perianal abscess who is not ill. Treatment should include an oral antistaphylococcal antibiotic, frequent soaking of the area, and close outpatient monitoring. Surgery should be reserved for selected cases in which there has been no response to medical treatment, the abscess is very large, or the child is ill. I concur with the authors that a well-controlled prospective study of all infants with perianal abscesses will be necessary to definitively determine optimal management.

	FOOTNOTES

 
Accepted Apr 30, 2007.

Address correspondence to Myles B. Abbott, MD, FAAP, East Bay Pediatrics, 2999 Regent St, Berkeley, CA 94705. E-mail: mabbottmd{at}aol.com

The author has indicated he has no financial relationships relevant to this article to disclose.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

	REFERENCES

TOP REFERENCES

 

1. Christison-Lagay ER, Hall JF, Wales PW, et al. Nonoperative management of perianal abscess in infants is associated with decreased risk for fistula formation. Pediatrics. 2007;120(3) . Available at: www.pediatrics.org/cgi/content/full/120/3/e548
2. Stites T, Lund DP. Common anorectal problems. Semin Pediatr Surg. 2007;16 :71 –78[CrossRef][Medline]

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Web of Science (2) Citing Articles via Google Scholar Google Scholar Articles by Abbott, M. B. Search for Related Content PubMed PubMed Citation Articles by Abbott, M. B. Related Collections Surgery Social Bookmarking                         What's this?