A perianal abscess heralds with a painful swelling around the anal orifice, sometimes pain is felt but swelling is not seen as the abscess remains deep seated. Initially there is a sense of heaviness in the perianal area and then gradually pain starts. The patient feels pain almost in all positions, but more in sitting position or during passing stool. Patient cannot drive, ride motor cycle or bi-cycle. In one or two days pain becomes intense and patient visits doctor's clinic; sometimes there may be associated fever, anorexia, constipation or diarrhoea.
In my clinical practice I do get many a patient with perianal abscess. A considerable number of patients with painful perianal swelling comes after 2/3 days having a course of self-medication – mostly analgesics and sometimes antibiotics. Those who are conscious enough about the harm of self-medication visit my clinic to get medicines prescribed. After examination if I suggest operation i.e. incision and drainage (I & D) under saddle block many of them refuse with an anticipation that, this simple case of abscess will either subside or burst out spontaneously and surgery is an over-treatment. I do partially agree with this statement. In the natural course of healing an inflamed lesion is either going to subside or burst out after pus formation, but an Ayurvedic surgeon knows the different stages of this lesion – Amavastha, Pacchamanavastha
and Pakvavastha. As far as treatment is concerned, one should definitely evaluate the stage of inflammation. In amavastha and early pacchamanavastha the condition is possible to be reversed with adequate conservative treatment; but in late pacchamanavastha and pakvavastha,
there will be suppuration and the pus is to be drained out. It is also true that, pus is going to be burst out if surgically not drained out.
People often ask me, why do I suggest surgical intervention to drain out pus and not allow it to be drained out spontaneously. The answer is "gambhiranugato dvaram alabhamanah puyah svamashrayamavadayortsangam mahantam avakasham kritva nadi janayitva kricchasadhyo bhavat asadhyo veti" (Sushruta Samhita sutrasthana 17/9) i.e. "pus remaining deep inside, not getting an opening, creates a big tear in its own place, leading to formation of sinus; then it becomes either difficult to cure or incurable". An early I&D reduces the chance of sinus or fistula formation.
One more question I often do come across is why doing I&D under saddle block or GA and not under local anaesthesia. The answer is, perianal abscess is a potential cause of anal fistula formation. To reduce the incidence of fistula formation a perianal abscess needs to be drained with cruciate incision and excision of flaps. This gives an wide opening to drain out the pus and inflammatory fluid properly, a thorough cleaning of abscess cavity requires good manipulation which is often painful under local anaesthesia. There may be a need of anal stretching. Sometimes the abscess cavity may be communicating with the anal canal or rectum. These conditions require handling of guda marma (internal anal sphincter) – a sadya pranahara marma (a vital structure on the body, injury of which causes immediate death). Stretching of internal anal sphincter is to be done under adequate anaesthesia as a life-saving measure. In most of the cases, if anal fistula is present, ksharasutra is placed in the same sitting after proper draining the abscess cavity. That is why I do suggest the procedure to be done under saddle block or GA. This provides a good vision which helps the surgeon to examine properly and take right decision.
An early draining of perianal abscess reduces the chance of fistula formation. I would like to share one case I operated few months back. A 19-year old male patient visited my clinic with a complaint of painful perianal swelling for two days. It was a case of abscess as I diagnosed and advised I&D under GA. The patient refused and went off. A couple of days later he again visited with a drained abscess (fig. 1). This time his guardian agreed for surgery (fig. 2), but by this time a 3cm long sinus tract was formed (fig. 3) which was treated with ksharasutra.
I would like to conclude with following words:
11 Jul, 2017
30 Jun, 2017
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