ORIGINAL ARTICLE

German S3 guideline: anal abscess

Andreas Ommer & Alexander Herold & Eugen Berg &
Alois Frst & Marco Sailer & Thomas Schiedeck
Accepted: 16 January 2012 / Published online: 24 February 2012
#Springer-Verlag 2012
Abstract
Background The incidence of anal abscess is relatively
high, and the condition is most common in young men.
Methods A systematic review of the literature was
undertaken.
Results This abscess usually originates in the proctodeal
glands of the intersphincteric space. A distinction is made
between subanodermal, intersphincteric, ischioanal, and supra-
levator abscesses. The patient history and clinical examination
are diagnostically sufficient to establish the indication for
surgery. Further examinations (endosonography, MRI) should
be considered in recurrent abscesses or supralevator abscesses.
The timing of the surgical intervention is primarily determined
by the patient's symptoms, and acute abscess is generally an
indication for emergency treatment. Anal abscesses are treated
surgically. The type of access (transrectal or perianal) depends
on the abscess location. The goal of surgery is thorough
drainage of the focus of infection while preserving the sphinc-
ter muscles. The wound should be rinsed regularly (using tap
water). The use of local antiseptics is associated with a risk of
cytotoxicity. Antibiotic treatment is only necessary in excep-
tional cases. Intraoperative fistula exploration should be con-
ducted with extreme care if at all; no requirement to detect
fistula should be imposed. The risk of abscess recurrence or
secondary fistula formation is low overall, but they can result
frominsufficient drainage. Primary fistulotomy should only be
performed in case of superficial fistulas and by experienced
surgeons. In case of unclear findings or high fistulas, repair
should take place in a second procedure.
Conclusion In this clinical S3 guideline, instructions for
diagnosis and treatment of anal abscess are described for
the first time in Germany.
Keywords Anal abscess
.
Diagnostic
.
Operative treatment
.
Stool incontinence
.
Fistula-in-ano
Introduction
Anal fistula, with its acute form of anal abscess, is a common
disease with an incidence of about 2 cases per 10,000 inhab-
itants per year. It is most likely to occur between the ages of 30
and 50 [1]. Men are more likely to be affected than women [2].
Methods
The content of the present guideline is based on an extensive
review of literature (Fig. 1). Definitions of strength of
A. Ommer (*)
End-und Dickdarmpraxis Essen,
Rttenscheider Strasse 66,
45130 Essen, Germany
e-mail: aommer@online.de
A. Herold
End-und Dickdarmzentrum,
Mannheim, Germany
E. Berg
Prosper Hospital,
Recklinghausen, Germany
A. Frst
Caritas Krankenhaus St.Josef,
Regensburg, Germany
M. Sailer
Bethesda-Krankenhaus,
Hamburg, Germany
T. Schiedeck
Klinikum Ludwigsburg,
Ludwigsburg, Germany
Int J Colorectal Dis (2012) 27:831837
DOI 10.1007/s00384-012-1430-x
AWMF-Register Nr. 088/005e
evidence, recommendation grade, and strength of consensus
have been established [35] (Tables 1 and 2). In some cases
due to a large difference between evidence level and clinical
practice, the recommendation grade was defined as point of
clinical consensus. The guidelines group (Table 3) pro-
duced the text in the context of two consensus conferences.
Etiology and classification
In most cases, anal abscess originates from the cryptogland-
ular tissue (proctodeal glands) of the intersphincteric space
(Fig. 2) [6]. The number of glands varies; they are more
frequently found posteriorly [7, 8] and more are found in
men than in women [9].
Abscesses initially formin the intersphincteric space. From
there, they can expand directly toward the perianal region and
present as subanodermal or subcutaneous abscesses. An ab-
scess that breaks through the sphincter ani externus muscle
results in ischioanal abscess, previously referred to as ischior-
ectal abscess, and proximal extension into the pelvirectal fossa
gives rise to supralevator abscess. A distinction is made be-
tween four types of abscess on the basis of origin (Fig. 2):
1. Subanodermal abscess
2. Intersphincteric abscess
3. Ischioanal abscess
4. Supralevator abscess
Fig. 1 Literature search, methodology
Table 1 Definition of evidence levels and recommendation grades [3, 4]
Strength of
recommendation
Level of
evidence
Types of treatment studies
A (should) 1a Systematic review of randomized
controlled studies (RCT)
1b A suitably planned RCT
1c All-or-nothing approach
B (ought to) 2a Systematic review of good-quality
cohort studies
2b A good-quality cohort study, including
RCT with moderate follow-up (<80%)
0 (may) 3a Systematic review of good-quality
casecontrol studies
3b A good-quality casecontrol study
0 (may) 4 Case series, including poor-quality
cohort and casecontrol studies
0 (may) 5 Opinions without explicit critical
assessment, physiological models,
comparisons, or principles
Table 2 Classification of the strength of consensus [5]
Strong consensus Agreement of >95% of participants
Consensus Agreement of 7595% of participants
Majority agreement Agreement of 5075% of participants
No consensus Agreement of <50% of participants
Table 3 Members of the anal fistula guidelines group
For the German Society of General and Visceral Surgery (DGAV), the
Surgical Working Group for Coloproctology (CACP), the German
Society of Coloproctology (DGK), and the Association of
Coloproctologists in Germany (BCD)
Dr. A. Ommer, Essen, Germany
Prof. Dr. A. Herold, Mannheim, Germany
Dr. E. Berg, Recklinghausen, Germany
Priv.-Doz. Dr. St. Farke, Delmenhorst, Germany
Prof. Dr. A. Frst, Regensburg, Germany
Priv.-Doz. Dr. F. Hetzer, Schaffhausen, Switzerland
Dr. A. Khler, Duisburg, Germany
Prof. Dr. S. Post, Mannheim, Germany
Dr. R. Ruppert, Munich, Germany
Prof. Dr. M. Sailer, Hamburg, Germany
Prof. Dr. Th. Schiedeck, Ludwigsburg, Germany
Dr. B. Strittmatter, Freiburg, Germany
For the German Society of Dermatology (DDG)
Dr. B. H. Lenhard, Heidelberg, Germany
For the Working Group for Urogynecology and Plastic Pelvic Floor
Reconstruction (AGUB) of the German Society for Gynecology
and Obstetrics
Prof. Dr. W. Bader, Hannover, Germany
For the German Society of Urology (DGU)
Prof. Dr. J. E. Gschwend, Munich, Germany
For the German Society of Digestive and Metabolic Diseases (DGVS)
Prof. Dr. H. Krammer, Mannheim, Germany
Prof. Dr. E. Stange, Stuttgart, Germany
832 Int J Colorectal Dis (2012) 27:831837
The incidence of the individual types varies, with super-
ficial types being much more common [10, 11].
These abscesses contain a mixed flora of intestinal bac-
teria (especially Escherichia coli, Bacteroides) and skin-
dwelling bacteria (Staphylococcus aureus). Their differenti-
ation is generally irrelevant for treatment purposes, howev-
er. This guideline does not cover special situations (MRSA
colonization, tuberculosis, actinomycosis, and gonorrhea) or
abscesses caused by foreign body ingestion. A publication
from 2011 discusses smoking as a risk factor for abscess or
fistula formation [12].
Symptoms and diagnosis
The symptoms of anal abscess include painful swelling and
possible reddening with acute onset in the anal region.
Because of the pain involved, the rectal examination should
be kept to a minimum. Proctoscopy and rectoscopy supply
little additional information and cause the patient severe
pain. Preoperative advanced diagnostics, particularly imag-
ing, is not required for the majority of patients.
Supralevator abscess is a different matter, as inspection
does not provide any information. Patients often experience
general symptoms such as fever and malaise in these cases.
In these cases, rectal palpation often reveals induration or
even fluctuation. Patients typically experience dull pain in
the lesser pelvis or back pain [13]. In case of unclear find-
ings, endosonography, computed tomography, or magnetic
resonance imaging (MRI) can help localize the abscess [14].
Please refer to the information provided in the clinical
guideline Cryptoglandular anal fistula [15, 16] for infor-
mation on the usefulness of these procedures.
Further procedures are performed intraoperatively under
anesthesia. They include inspection of the anal canal to con-
firm or exclude internal fistula opening. The area may be
carefully probed using a curved probe, but extensive exami-
nation is not recommended. Endosonography allows localiza-
tion of the abscess, so that the best surgical access route can be
chosen, particularly in case of supralevator abscesses.
Before surgical intervention, sphincter function should be
assessed via a history and, if applicable, incontinence score,
particularly in view of possible primary fistulotomy. Manom-
etry does not provide additional information and is not diag-
nostically valuable, particularly in the acute abscess stage.
In summary, anal abscess is diagnosed using clinical
signs and symptoms, inspection, and palpation. Imaging
diagnostics should be considered only in case of supraleva-
tor abscess or recurrent abscess.
Recommendation grade: point of clinical consensus
Strength of consensus: strong consensus
Treatment
Surgical indication
Anal abscess is treated surgically, with clinical signs and
symptoms determining the timing of the surgical interven-
tion. The purpose of the treatment is to decompress the
abscess cavity to prevent progressive inflammation with
potentially life-threatening complications (e.g., pelvic sepsis
or Fournier gangrene [17]).
While acute abscess is an emergency, surgical interven-
tion is also recommended in case of spontaneous perforation
since insufficient drainage may cause abscess recurrence or
fistula formation. Conservative treatment options, particu-
larly antibiotic treatment, are unlikely to be successful and
are not considered appropriate. The microbiological results
of abscess smears are clinically irrelevant in most cases and
are therefore unnecessary.
Recommendation grade: point of clinical consensus
Strength of consensus: strong consensus
Abscess drainage technique
The surgical technique depends on the abscess type [18].
Generally, abscess surgery is performed under general or
regional anesthesia.
Fig. 2 Classification of anal abscesses
Int J Colorectal Dis (2012) 27:831837 833
In subanodermal and ischioanal abscesses, surgeons
make either a perianal incision or an excision that removes
an oval-shaped section of tissue. The latter is preferable
from the perspective of drainage. The incision should run
parallel to the fibers of the sphincter ani externus muscle.
Access to intersphincteric abscesses varies with location.
For abscesses that are entirely intra-anal in location and
feature a connection to the anal canal, transanal drainage,
possibly with internal sphincterotomy, is recommended. For
subanodermally located abscesses, perianal access with or
without fistulotomy is suitable.
Drainage of the supralevator abscess can be performed trans-
rectally or perianally. Endosonography is the most important
diagnostic procedure, as it can show whether the muscle plate
of the levator ani muscle is intact. If the levator ani muscle is
intact and the abscess is limited to the pelvirectal fossa, trans-
rectal drainage can be performed to prevent fistula formation.
If the abscess has already broken through the levator ani
muscle into the ischioanal fossa, transischioanal drainage is
performed. It is important that the long drainage route
remains open. A drain (e.g., Penrose, Easyflow, or similar)
may be put in place for a few days if necessary.
An overview of current publications is available in the
evidence table that is attached to the full version of the guide-
lines. Only three studies were published after 2000. The goal
of surgical intervention is the thorough drainage of the inflam-
matory tissue without relevant damage to the adjacent healthy
structures, particularly the sphincter apparatus.
Recommendation grade: point of clinical consensus
Strength of consensus: strong consensus
Causes of abscess recurrence
Insufficient drainage [19, 20] and late drainage [21] can
cause early recurrence. Sufficient drainage of anal abscesses
is therefore important to prevent recurrence and fistula for-
mation. In case of extensive abscess, generous criteria should
be applied when determining the indication for revision under
anesthesia.
Evidence level: 4
Recommendation level: B (justification: for ethical reasons,
this generally accepted statement cannot be tested using
randomized studies)
Strength of consensus: strong consensus
Indications for primary fistula repair
The available literature indicates that fistulas identified in
the context of abscess incision do not always require follow-
up surgery and that the fistula may spontaneously close after
thorough draining [10, 22, 23].
A total of five randomized studies compare excision alone
with primary fistulotomy [2428]. They indicate that primary
fistulotomy reduces revision rates but is associated with a
higher incontinence rate. Unfortunately, none of the studies
specify the type of treated fistulas. It seems even more signif-
icant, however, that the majority of patients whose fistula was
left in place did not undergo another surgical procedure, which
suggests that spontaneous healing is possible.
In superficial fistulas, primary fistulotomy appears useful to
prevent recurrence and to spare the patients, who are usually
young, a second procedure [29]. As described for anal fistula,
however, the incontinence rate increases with the amount of
sphincter muscle that has been divided and with the number of
previous interventions. In this context, it is important to note
that abscess excision is often performed as an emergency
procedure and by less experienced surgeons, so that the deci-
sion about fistulotomy should be left to experienced surgeons in
the context of a second procedure. In cases with known com-
plex fistula, insertion of a Seton drain can achieve good drain-
age and prepare the fistula canal for a second procedure under
elective conditions. However, the literature indicates that a
relevant portion of the confirmed fistulas closes spontaneous-
ly. The value of a Seton drain has not been definitively agreed.
Current publications [3032], some of which are the subject of
lively debate, do not indicate that placement of a Seton drain
represents an advantage for successful plastic fistula closure.
In summary, superficial fistulas should be treated with
primary fistulotomy performed by experienced surgeons. In
case of unclear findings or high fistulas, repair should be
performed in a second procedure.
Evidence level: 1a
Recommendation level: A
Strength of consensus: strong consensus
Incidence of confirmed secondary fistula
In addition to abscess recurrence, the development of an
anal fistula that requires another intervention is the most
common sequela to abscess surgery. According to the liter-
ature, only some of the abscesses result in the development
of chronic fistula [23, 33, 34]. One literature review reports
chronic fistulas in 7% to 66% of cases (median 16%) and
abscesses in 4% to 31% of cases (median 13%) [35].
The rate of confirmed secondary fistulas depends on the
location of the abscess. Szener et al. [34], for instance, found
anal fistula following 14% of cases of subanodermal abscess,
35% of intersphincteric abscess, and 60% of ischioanal abscess.
In summary, the rate of abscess recurrence and chronic
fistulas is relatively low. That means that only a small portion
of abscesses leads to chronic fistulas. The probability of fistula
development is a function of abscess location. In subanoder-
mal or intersphincteric anal abscesses, fistulas are rare and
834 Int J Colorectal Dis (2012) 27:831837
predominantly superficial, but the rate of complex fistulas is
distinctly higher in ischioanal and supralevator abscesses [10].
Incidence depends on the abscess type and can reach 40% in
ischioanal and supralevator abscesses [26, 28, 36, 37]. There-
fore, extensive fistula exploration is not recommended in the
initial procedure.
Evidence level: 3
Recommendation level: B (justification: for ethical rea-
sons, this generally accepted statement cannot be tested
using randomized studies)
Strength of consensus: strong consensus
Surgical treatment: reviews
Compared to cryptoglandular anal fistula, publications on
treatment options for anal abscesses are very scarce. They
generally date from before 1990, and only a small portion of
the papers analyzed was published after 2000.
The surgical treatment of anal abscess has been the subject
of two meta-analyses, one Cochrane analysis, and the guide-
lines of the American Society of Colon and Rectal Surgeons.
These analyses are based on the six published randomized
studies only or are of a general nature [3841].
Perioperative management
Specific bowel preparation is not required and would be
impossible in most cases because of the patient's pain.
Postoperative care following anal surgery is unproblematic.
The external wound heals by secondary intention and should
be rinsed regularly. Clear water is best for this purpose,
particularly since antiseptic solutions are associated with a
risk of cytotoxicity. Regular wound packing is not required
[42]. However, the external opening of the drainage must not
be allowed to close prematurely. The value of accompanying
antibiotic treatment has not yet been sufficiently clarified [33,
34, 4346]. In general, however, antibiotic treatment appears
to be indicated in exceptional cases only (immune deficiency,
serious phlegmonous inflammation).
Evidence level 4
Recommendation level: B (justification: for ethical rea-
sons, this generally accepted statement cannot be tested
using randomized studies)
Strength of consensus: strong consensus
Complications
Complications following anal abscess surgery do not differ
from complications following other anal surgeries and
primarily involve postoperative hemorrhage and urinary re-
tention [47]. Incontinence is rare following abscess surgery
alone and can be largely prevented by a sphincter-preserving
procedure [48].
Recommendation grade: point of clinical consensus
Strength of consensus: strong consensus
Core statements
1. The incidence of anal abscess is relatively high. They
are most common in young men.
2. The abscess usually originates from the proctodeal glands
of the intersphincteric space. A distinction is made be-
tween subanodermal, intersphincteric, ischioanal, and
supralevator abscesses.
3. The patients history and clinical examination are diag-
nostically sufficient to establish the indication for sur-
gery. Further examinations (endosonography, MRI)
should be considered in case of recurrent abscesses or
supralevator abscesses.
Recommendation grade: point of clinical consensus
Strength of consensus: strong consensus
4. The timing of the surgical intervention primarily
depends on the patient's signs and symptoms, with acute
abscess always representing an indication for emergency
surgery.
Recommendation grade: point of clinical consensus
Strength of consensus: strong consensus
5. Anal abscesses are treated surgically. Access (trans-
rectal or perianal) depends on the location of the
abscess. The goal of surgery is thorough drainage of
the infection focus while preserving the sphincter
structures.
Recommendation grade: point of clinical consensus
Strength of consensus: strong consensus
6. Intraoperative fistula exploration requires extreme care,
and excessive examination to confirm a fistula is not
recommended.
Evidence level: 3
Recommendation level: B
Strength of consensus: strong consensus
7. Overall, the risk of abscess recurrence or secondary
fistula formation is low; these conditions can result from
insufficient drainage.
Evidence level: 4
Recommendation level: B
Strength of consensus: strong consensus
8. Primary fistulotomy should only be performed in super-
ficial fistulas and by experienced surgeons. In case of
unclear findings or high fistulas, repair should be per-
formed in a second procedure.
Int J Colorectal Dis (2012) 27:831837 835
Evidence level: 1a
Recommendation level: A
Strength of consensus: strong consensus
9. The wound should be rinsed regularly (using tap water).
The use of local antiseptics is associated with a risk of
cytotoxicity. Antibiotic treatment is required only in ex-
ceptional cases.
Recommendation level: B
Strength of consensus: strong consensus
Conflicts of interest Dr. Ommer received an honorarium from the
DGAV for generating four guidelines on anal fistula. Furthermore,
some of his travel and accommodation costs were reimbursed by Gore
and Johnson & Johnson. He received an honorarium for presentations
at continued education events from Kade and MSD. Prof. Herold
received financial support for conferences from the Falk Foundation,
Johnson & Johnson, Prostrakan, MSD, and Aesculap. Additional proj-
ects were supported by external funding from the following companies:
Cook, Gore, SLA-Pharma, Falk Foundation, and Kreussler. Dr. Berg
was reimbursed for conference registration fees as well as travel and
accommodation costs by Johnson & Johnson. He received an honorar-
ium from Falk Foundation and Johnson & Johnson for preparatory
work associated with continued education events. Prof. Frst received
funding for conference travel from Johnson & Johnson and Braun-
Aeskulap, and he received an honorarium for conducting commis-
sioned clinical studies from Bayern Innovativ GmbH. Prof. Sailer
received an honorarium for continued education events from Covidien,
Johnson & Johnson, Falk Foundation, and Hitachi Medical. Prof.
Schiedeck was reimbursed for registration fees and travel and accom-
modation costs and received an honorarium for preparatory work
associated with scientific continued education events by Aesculap
Akademie GmbH, Falk Foundation e.V., Johnson & Johnson, and
Medical GmbH. He received an honorarium from Solesta and Medela
for conducting commissioned clinical studies.
References
1. Zanotti C, Martinez-Puente C, Pascual I et al (2007) An assess-
ment of the incidence of fistula-in-ano in four countries of the
European Union. Int J Color Dis 22:14591462
2. Sainio P (1984) Fistula-in-ano in a defined population. Incidence
and epidemiological aspects. Ann Chir Gynaecol 73:219224
3. Schmiegel W, Pox C, Reinacher-Schick A et al (2008) S3-Leitlinie
Kolorektales Karzinom. Z Gastroenterol 46:173
4. Phillips B, Ball C, Sackett D, et al. (2009) Oxford Centre for
Evidence-based medicinelevels of evidence. www.cebm.net/
index.aspx?o01025
5. Hoffmann JC, Fischer I, Hohne W, Zeitz M, Selbmann HK (2004)
Methodological basis for the development of consensus recom-
mendations. Z Gastroenterol 42:984986
6. Klosterhalfen B, Offner F, Vogel P, Kirkpatrick CJ (1991) Ana-
tomic nature and surgical significance of anal sinus and anal
intramuscular glands. Dis Colon Rectum 34:156160
7. Abeysuriya V, Salgado LS, Samarasekera DN (2010) The distri-
bution of the anal glands and the variable regional occurrence of
fistula-in-ano: is there a relationship? Tech Coloproctol 14:317
321
8. Seow-Choen F, Ho JM (1994) Histoanatomy of anal glands. Dis
Colon Rectum 37:12151218
9. Lilius HG (1968) Fistula-in-ano, an investigation of human foetal
anal ducts and intramuscular glands and a clinical study of 150
patients. Acta Chir Scand Suppl 383:788
10. Ommer A, Athanasiadis S, Happel M, Khler A, Psarakis E (1999)
Die chirurgische Behandlung des anorektalen Abszesses. Sinn und
Unsinn der primren Fistelsuche. Coloproctology 21:161169
11. Ramanujam PS, Prasad ML, Abcarian H, Tan AB (1984) Perianal
abscesses and fistulas. A study of 1023 patients. Dis Colon Rectum
27:593597
12. Devaraj B, Khabassi S, Cosman BC (2011) Recent smoking is a
risk factor for anal abscess and fistula. Dis Colon Rectum 54:681
685
13. Herr CH, Williams JC (1994) Supralevator anorectal abscess pre-
senting as acute low back pain and sciatica. Ann Emerg Med
23:132135
14. Toyonaga T, Matsushima M, Tanaka Y et al (2007) Microbiolog-
ical analysis and endoanal ultrasonography for diagnosis of anal
fistula in acute anorectal sepsis. Int J Color Dis 22:209213
15. Ommer A, Herold A, Berg E, et al. (2011) S3-Leitlinie Krypto-
glandulre Analfistel. AWMF online. http://www.awmf.org/
leitlinien/detail/ll/088-003.html
16. Ommer A, Herold A, Berg E et al (2011) Clinical practice guide-
line: cryptoglandular anal fistula. Dtsch Arztebl Int 108:707713
17. Yilmazlar T, Ozturk E, Ozguc H et al (2010) Fournier's gangrene:
an analysis of 80 patients and a novel scoring system. Tech
Coloproctol 14:217223
18. Nomikos IN (1997) Anorectal abscesses: need for accurate ana-
tomical localization of the disease. Clin Anat 10:239244
19. Onaca N, Hirshberg A, Adar R (2001) Early reoperation for
perirectal abscess: a preventable complication. Dis Colon Rectum
44:14691473
20. Chrabot CM, Prasad ML, Abcarian H (1983) Recurrent anorectal
abscesses. Dis Colon Rectum 26:105108
21. Yano T, Asano M, Matsuda Y et al (2010) Prognostic factors for
recurrence following the initial drainage of an anorectal abscess.
Int J Color Dis 25:14951498
22. Hmlinen KP, Sainio AP (1998) Incidence of fistulas after drain-
age of acute anorectal abscesses. Dis Colon Rectum 41:1357
1361, discussion 1361-2
23. Rizzo JA, Naig AL, Johnson EK (2010) Anorectal abscess and
fistula-in-ano: evidence-based management. Surg Clin North Am
90:4568, Table of contents
24. Hebjorn M, Olsen O, Haakansson T, Andersen B (1987) A ran-
domized trial of fistulotomy in perianal abscess. Scand J Gastro-
enterol 22:174176
25. Ho YH, Tan M, Chui CH et al (1997) Randomized controlled trial
of primary fistulotomy with drainage alone for perianal abscesses.
Dis Colon Rectum 40:14351438
26. Schouten WR, van Vroonhoven TJ (1991) Treatment of anorectal
abscess with or without primary fistulectomy. Results of a pro-
spective randomized trial. Dis Colon Rectum 34:6063
27. Tang CL, Chew SP, Seow-Choen F (1996) Prospective randomized
trial of drainage alone vs. drainage and fistulotomy for acute
perianal abscesses with proven internal opening. Dis Colon Rec-
tum 39:14151417
28. Oliver I, Lacueva FJ, Perez Vicente F et al (2003) Randomized
clinical trial comparing simple drainage of anorectal abscess with
and without fistula track treatment. Int J Color Dis 18:107110
29. Fucini C (1991) One stage treatment of anal abscesses and fistulas.
A clinical appraisal on the basis of two different classifications. Int
J Color Dis 6:1216
30. Aboulian A, Kaji AH, Kumar RR (2011) Early result of ligation of
the intersphincteric fistula tract for fistula-in-ano. Dis Colon Rec-
tum 54:289292
31. Garg PK, Jain BK (2011) Seton drainage in high anal fistula. Int J
Color Dis 26:1495
836 Int J Colorectal Dis (2012) 27:831837
32. Mitalas LE, van Wijk JJ, Gosselink MP et al (2010) Seton drainage
prior to transanal advancement flap repair: useful or not? Int J
Color Dis 25:14991502
33. Lohsiriwat V, Yodying H, Lohsiriwat D (2011) Incidence and
factors influencing the development of fistula-in-ano after incision
and drainage of perianal abscesses. J Med Assoc Thai 93:6165
34. Szener U, Gedik E, Kessaf Aslar A et al (2011) Does adjuvant
antibiotic treatment after drainage of anorectal abscess prevent
development of anal fistulas? A randomized, placebo-controlled,
double-blind, multicenter study. Dis Colon Rectum 54:923929
35. Hamadani A, Haigh PI, Liu IL, Abbas MA (2009) Who is at risk
for developing chronic anal fistula or recurrent anal sepsis after
initial perianal abscess? Dis Colon Rectum 52:217221
36. Cox SW, Senagore AJ, Luchtefeld MA, Mazier WP (1997) Out-
come after incision and drainage with fistulotomy for ischiorectal
abscess. Am Surg 63:686689
37. Knoefel WT, Hosch SB, Hoyer B, Izbicki JR (2000) The initial
approach to anorectal abscesses: fistulotomy is safe and reduces
the chance of recurrences. Dig Surg 17:274278
38. Malik AI, Nelson H, and Tou S (2010) Incision and drainage of
perianal abscess with or without treatment of anal fistula (review).
Cochrane Database of Systematic Reviews 4: CD006827
39. Quah HM, Tang CL, Eu KW, Chan SY, Samuel M (2006) Meta-
analysis of randomized clinical trials comparing drainage alone vs
primary sphincter-cutting procedures for anorectal abscess-fistula.
Int J Color Dis 21:602609
40. Rickard MJ (2005) Anal abscesses and fistulas. ANZ J Surg 75:6472
41. Whiteford MH (2007) Perianal abscess/fistula disease. Clin Colon
Rectal Surg 20:102109
42. Tonkin DM, Murphy E, Brooke-Smith M et al (2004) Perianal
abscess: a pilot study comparing packing with nonpacking of the
abscess cavity. Dis Colon Rectum 47:15101514
43. Llera JL, Levy RC (1985) Treatment of cutaneous abscess: a
double-blind clinical study. Ann Emerg Med 14:1519
44. Macfie J, Harvey J (1977) The treatment of acute superficial
abscesses: a prospective clinical trial. Br J Surg 64:264266
45. Nunoo-Mensah JW, Balasubramaniam S, Wasserberg N et al
(2006) Fistula-in-ano: do antibiotics make a difference? Int J Color
Dis 21:441443
46. Stewart MP, Laing MR, Krukowski ZH (1985) Treatment of acute
abscesses by incision, curettage and primary suture without anti-
biotics: a controlled clinical trial. Br J Surg 72:6667
47. Toyonaga T, Matsushima M, Sogawa N et al (2006) Postoperative
urinary retention after surgery for benign anorectal disease: poten-
tial risk factors and strategy for prevention. Int J Color Dis 21:676
682
48. Ommer A, Wenger FA, Rolfs T, Walz MK (2008) Continence
disorders after anal surgerya relevant problem? Int J Color Dis
23:10231031
Annotation
The complete text of the guideline (in German) has been published in
Coloproctology 2011, 33: 378392 and online at http://www.awmf.
org/leitlinien/detail/ll/088-005.html.
Int J Colorectal Dis (2012) 27:831837 837