Acute paraproctitis: clinical guidelines

List of Abbreviations

IBD – inflammatory bowel disease

IAP – internal anal sphincter

MRI – magnetic resonance imaging

AP - acute paraproctitis

AF - anal fistula

TRUS – transrectal ultrasound

Terms and Definitions

An anal fistula is a pathological tract between the anal canal and the surrounding tissues and/or organs and/or the perianal skin.

Anal crypts (Crypts of Morgagni) are small depressions between the longitudinal mucosal folds (Columns of Morgagni), located directly above the dentate line in the upper third of the anal canal.

Anaerobic paraproctitis is an infection caused by clostridial species, characterized by an extremely severe clinical course.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Acute paraproctitis (AP) is an acute inflammation of the perirectal cellular tissue caused by the spread of a purulent-inflammatory process from the anal crypts and anal glands. The primary cause of AP is mixed intestinal microflora, most commonly represented by aerobic microorganisms [1-5].

Anaerobic paraproctitis is a distinct, life-threatening condition associated with a high mortality rate that requires completely different diagnostic and therapeutic approaches compared to acute aerobic paraproctitis and is not covered in these clinical guidelines.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Cryptogenic paraproctitis is the most common in clinical practice (about 90%), whereas paraproctitis secondary to other conditions—such as inflammatory bowel disease, tumors, pelvic cysts, teratomas, trauma, and radiation injury—is less frequent. The development of AP is driven by several predisposing factors: immunosuppression, microcirculatory disorders, gastrointestinal disturbances, and complications of hemorrhoids, anal fissures, or cryptitis. In pediatric patients, primary immunodeficiency states can be the cause of acute paraproctitis. Additionally, a congenital theory is considered, based on the concept of androgen-estrogen imbalance or excessive androgenic stimulation of the mucosal glands, which makes the crypts of Morgagni 1-2 mm deeper than usual [1-3,5-9].

1.3 Epidemiology of the Disease or Condition

AP is the most common condition in emergency proctology practice. Patients in this group account for about 1% of all admissions to surgical inpatient units and 5% of those suffering from colonic and rectal disorders [10,11]. Overall, the incidence of acute paraproctitis among the adult population is 16.1-20.2 per 100,000 [4,12,13]. From 2% to 7% of all pediatric surgical conditions requiring inpatient care are accounted for by patients with acute paraproctitis; AP can occur in any pediatric age group, but it overwhelmingly predominates in infants during their first months of life at 22-60% [14].

1.4 Features of Coding the Disease or Condition

ICD-10 Codes

Chapter – Diseases of the digestive system (XI).

Block – Abscess of anal and rectal regions (K61).

Code:

K61.0 Anal abscess

K61.1 - Rectal abscess

K61.2 - Anorectal abscess

K61.3 - Ischiorectal abscess

K61.4 - Intrasphincteric abscess

1.5 Classification of the disease or condition

By the localization of the lesion relative to anatomical landmarks:

a) subcutaneous;

b) submucosal;

c) intersphincteric;

d) ischioanal;

e) pelvirectal:

- pelvirectal;

- retrorectal.

By the localization of the inflammatory focus according to the conventional clock face:

a) posterior (from 4 to 8 o'clock on the conventional clock face);

b) anterior (from 10 to 2 o'clock on the conventional clock face);

c) lateral (from 8 to 10 o'clock or from 2 to 4 o'clock on the conventional clock face);

d) horseshoe (when the inflammation spreads to more than one of the zones listed above).

By the nature of the purulent tract (identified intraoperatively):

a) intrasphincteric;

b) transsphincteric;

c) extrasphincteric.

1.6 Clinical presentation of the disease or condition

The clinical presentation depends on the severity, localization, and extent of the inflammatory process. Subcutaneous paraproctitis presents as a dense, tender infiltrate in the perianal area with overlying skin hyperemia, which may have an area of fluctuation. Pain worsens during defecation, sitting, coughing, and walking. Symptoms of systemic toxicity are usually absent.

Submucosal paraproctitis manifests as pain during defecation and a low-grade fever; systemic toxicity symptoms are usually absent.

In infants, subcutaneous and submucosal localizations of acute paraproctitis predominate.

In ischioanal paraproctitis, in addition to pain, gluteal asymmetry is found, with skin hyperemia appearing in a delayed manner on days 5-6.

Ischioanal paraproctitis is accompanied by symptoms of systemic toxicity in the first days of the disease, followed by local changes in the perianal region: gluteal asymmetry, induration, and perianal skin hyperemia.

Pelvirectal paraproctitis has the most severe clinical course, dominated by pronounced symptoms of systemic toxicity (malaise, weakness, sleep disturbances, severe night sweats, chills, febrile temperature, headaches, dizziness). Pain in the lower abdomen may also occur. Indefinite symptoms persist on average for up to 12 days, followed by discomfort and pain in the anal canal during defecation, difficult bowel emptying, urinary hesitation, and possibly pain in the lower extremity on the side of the AP along the nerve pathways. Upon palpation, men may feel an urge to urinate due to the proximity of the infiltrate to the urethra [1,15-19].

2. Diagnostics, medical indications and contraindications for diagnostic methods

Criteria for establishing the diagnosis/condition — based on clinical examination data and, if necessary, instrumental diagnostics.

Differential diagnosis of AP caused by primary inflammation in the anal crypt area is performed with conditions such as:

1. Purulent-inflammatory diseases of the perineal, sacrococcygeal, and gluteal skin.

2. Bartholinitis.

3. Presacral cysts with an inflammatory component.

4. Perianal trauma.

5. Teratomas.

6. Anaerobic paraproctitis.

7. Rectal tumors.

8. Crohn's disease, ulcerative colitis complicated by an abscess.

9. Diverticular disease complicated by an abscess.

10. Complications of radiation therapy.

Principles of formulation of the diagnosis.

When formulating the diagnosis, the localization of the inflammatory process should be indicated. Examples of diagnosis formulations are given below:

1. Acute anterior horseshoe paraproctitis.

2. Acute posterior pelvirectal paraproctitis.

3. Acute retrorectal paraproctitis.

2.1 Complaints and Anamnesis

Characteristic complaints: discomfort and/or pain in the anus and perineum, worsening as the inflammatory process progresses; presence of a swelling in the soft tissues of the perianal, perineal, or gluteal region; difficulty with defecation and/or urination; local elevation of skin temperature over the inflammatory focus; and possible onset of lower abdominal pain [1,9,10].

The medical history may reveal:

· Immunosuppression due to a concurrent acute or chronic infection

· Hypothermia

· Vascular alterations secondary to diabetes mellitus

· Gastrointestinal disturbances (constipation and/or diarrhea)

· Cryptitis

· Anal fissure

· Primary or secondary immunodeficiency states (HIV infection)

· Previous anorectal or perineal surgical interventions.

2.2 Physical Examination

Comment. Clinical examination and digital rectal examination are performed with the patient in the gynecological position for lithotomy or in the knee-chest position.

Standard clinical examination includes inspection of the perineum and anus, assessing the severity and extent of the inflammatory process.

Standard digital rectal examination can determine:

- localization of the inflamed crypt (tenderness of the wall) on the side of the infiltrate;

- bulging of the rectal wall, pain, and smoothing of folds on the affected side;

- in retrorectal paraproctitis — bulging in the posterior rectal wall area, as well as increased pain upon pressure on the coccyx;

- in pelviorectal paraproctitis — tenderness of one of the rectal walls, infiltration of the intestinal wall, or a dense infiltrate beyond it. In later stages, thickening of the bowel wall is determined, its displacement from the outside, followed by bulging of an elastic, sometimes fluctuating formation into the lumen, over which the intestinal mucosa may remain mobile. When the inflammation spreads to the prostate gland and urethra, palpation of the rectal wall causes painful urinary urgency [1, 20].

2.3 Laboratory Diagnostics

Specific laboratory diagnostics for acute paraproctitis are lacking. Laboratory diagnostic tests should be performed in patients during the diagnosis and treatment of acute paraproctitis to exclude concomitant diseases and conditions. In a complete blood count, leukocytosis may be determined in the presence of extensive inflammatory lesions.

2.4 Instrumental Diagnostics

In most cases, instrumental diagnostics are not required to diagnose acute paraproctitis.

Comment: transrectal ultrasound of the rectum is performed to assess the localization and size of the purulent cavity, the degree of involvement of the rectal wall and the anal sphincter complex in the inflammatory process [24-27]. The diagnostic accuracy of ultrasound reaches 90% [24].

Comment: MRI provides anatomical detail and is a non-contact imaging method. Disadvantages of the method include high cost, the need for an MRI specialist, and long acquisition time.

2.5 Other Procedures

Microbiological (culture) examination of purulent discharge for aerobic and facultatively anaerobic microorganisms is not a mandatory diagnostic method, but it is advisable for determining further treatment tactics, and for excluding/confirming anaerobic or other specific bacterial flora. It consists of identifying the microflora species of the purulent focus to clarify the diagnosis and administer adequate antibiotic therapy. Material is collected in the operating room during abscess puncture [5, 31, 32].

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 General Principles of Acute Paraproctitis Treatment

The main method of treatment for acute paraproctitis is surgical.

Surgery should be performed within the first few hours after diagnosis verification.

The goal of surgery is the opening and drainage of the abscess, searching for and, if possible, eliminating the affected crypt and purulent tract [1, 33-40].

Indications for hospitalization: a verified diagnosis of acute paraproctitis [3, 10].

The type of surgical intervention depends on the localization of the abscess and the extent of the inflammatory infiltrate in the surrounding tissues [1, 33-38].

In infants, the possibility of conservative treatment for subcutaneous paraproctitis is considered. Opening of acute paraproctitis must be performed if there is a likelihood of abscess spread [41-45].

For adults: Grade of recommendation – B (level of evidence – 1).

For children: Grade of recommendation – C (level of evidence – 4).

3.2 Opening of Acute Purulent Paraproctitis

Comment. If clear verification of the affected crypt is absent, the surgical intervention is limited to opening and drainage of the abscess.

Opening and drainage of subcutaneous and ischioanal acute paraproctitis.

Method: A semilunar incision is made on the affected side, in the central part of the abscess, cutting through the skin and subcutaneous tissue. Abscess drainage is performed in such a way that no pockets remain deep in the wound and drainage is adequate. For this purpose, the skin wound is widened and drained.

Opening and drainage of pelviorectal acute paraproctitis.

Method: A semilunar incision is made on the affected side, at least 3 cm away from the anal verge, cutting through the skin, subcutaneous, and ischioanal tissue. A longitudinal incision is made through the muscle tissue of the pelvic diaphragm. This manipulation must be performed under visual control. If it cannot be performed under direct vision, muscle splitting can be performed bluntly — with a finger, clamp blades, or a Bozeman forceps. Abscess drainage is performed in such a way that no pockets remain deep in the wound and drainage is adequate.

Opening and drainage of retrorectal paraproctitis.

Indications: abscesses localized in the retrorectal space.

Method: An incision of the skin is made midway between the projection of the coccyx tip and the posterior edge of the anal opening, up to 5 cm in length. After evacuation of pus, the wound is treated with antiseptic solutions. The edge of the wound adjacent to the bowel wall is retracted using a hook to properly expose the posterior wall of the anal canal surrounded by the sphincter muscles.

Opening and drainage of horseshoe paraproctitis.

Method: The scope of surgical intervention depends on the location of the abscess relative to the sphincter muscles.

3.3 Opening and drainage of acute paraproctitis, excision of the affected crypt, placement of an elastic draining setton

Comment.

Method: A wide semilunar skin incision is made on the affected side; then, after evacuation of pus and discovery of the purulent tract, the incision is extended to the midline. From the lumen of the intestine, a circumscribing incision is made around the affected crypt, extending along the entire length of the anal canal until it connects with the corner of the perineal wound. A narrow strip of the anal canal lining and perianal skin is excised. Through the opening at the site of the removed crypt, an elastic drain is passed, one end of which is brought out of the perineal wound at the midline, and the other through the internal opening in the bowel lumen. The ends of the drain are connected to each other and fixed together with a ligature. The drain must not compress or cut through the involved tissues. The elastic draining setton should not be removed until a consolidated fistula has formed [52, 53].

3.4 Radical Surgeries in Acute Paraproctitis

Commentary.

Procedure: An examination of the anal canal is performed to locate the affected crypt of the internal fistula opening. A dye test is used to clearly visualize the purulent cavity and detect the affected crypt. A probe with a button end is used to clarify the position of the tract relative to the sphincter fibers. After this, a wide semi-lunar skin incision is made on the affected side, followed by cutting the purulent tract into the rectal lumen and excising the affected anal crypt. The probability of acute paraproctitis recurrence is up to 6% [53].

3.5 Treatment of Acute Paraproctitis in Neutropenia

Neutropenia significantly alters the clinical presentation and course of infectious processes in tissues. Abscess formation under conditions of neutropenia is rare; tissue changes more commonly present as inflammatory infiltrates and necrosis [57-61]. Acute paraproctitis developing against the background of granulocytopenia is a severe complication associated with a high probability of sepsis (30%) under immunosuppression [60,61].

Commentary. It is advisable at the initial stage to use antibiotics (J01: Antibacterials for systemic use) active against gram-negative bacteria, including Pseudomonas aeruginosa. Administration of antibiotics (J01: Antibacterials for systemic use) must be intravenous only [51].

Commentary. Surgical intervention should be performed against the background of antibacterial therapy under general anesthesia. Antibacterial therapy should be continued in the postoperative period until signs of infection disappear [59].

Patients with severe neutropenia (absolute neutrophil count less than 1000x10⁹/L) and no tissue abscess are more successfully treated with antibiotic therapy alone [57,58,62]. The prognosis depends on the clinical situation. The mortality rate directly associated with perianal infectious complications among oncohematological patients in modern studies is less than 5% [57-60].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

After discharge from the hospital, for the duration of wound healing, it is advisable for all patients to be followed up by a coloproctologist, surgeon, or pediatric surgeon.

5. Prevention and Dispensary Observation

There is no specific prevention for acute paraproctitis. Prevention of acute paraproctitis mainly consists of general body-strengthening measures aimed at eliminating the etiological factors of the disease:

1) treatment and sanitization of acute and chronic infection foci;

2) management of chronic diseases – diabetes mellitus, atherosclerosis;

3) correction of functional disorders (constipation, diarrhea);

4) timely treatment of concomitant proctological diseases (hemorrhoids, anal fissures, cryptitis, etc.).

6. Organization of Medical Care

Medical care, with the exception of medical care within the framework of clinical trials, in accordance with Federal Law No. 323-FZ dated November 21, 2011 (as amended on December 28, 2022) "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation", and Government Decree of the Russian Federation No. 1968 dated November 17, 2021, "On Approval of the Rules for the Phased Transition of Medical Organizations to the Provision of Medical Care Based on Clinical Guidelines Developed and Approved in Accordance with Parts 3, 4, 6–9, and 11 of Article 37 of the Federal Law 'On the Fundamentals of Protecting the Health of Citizens in the Russian Federation'", is organized and provided:

1) in accordance with the regulations on the organization of medical care by types of medical care, approved by the authorized federal executive body;

2) in accordance with the care standards for the profile "coloproctology", which are mandatory for implementation throughout the Russian Federation by all medical organizations;

3) based on these clinical guidelines;

4) taking into account the standards of medical care approved by the authorized federal executive body.

Hospitalization of patients with acute paraproctitis is carried out on an emergency basis to perform surgical intervention within the first few hours after diagnosis verification. Treatment of this category of patients is carried out in a specialized coloproctological inpatient facility, or in its absence, in a surgical inpatient facility. For subcutaneous and submucosal abscess localization, treatment may be carried out in a day care unit, round-the-clock inpatient unit, or short-stay unit. Treatment in a day care unit and short-stay unit is possible in the absence of signs of general intoxication, absence of signs of decompensation of concomitant diseases, no evidence of paraproctitis against the background of neutropenia, and verified Crohn's disease. Medical care for acute paraproctitis patients is provided by coloproctologists, or in their absence, by surgeons or pediatric surgeons.

Indication for hospitalization:

· confirmed diagnosis of acute paraproctitis.

Indications for patient discharge:

· with sustained improvement, when the patient can continue outpatient treatment without detriment to health under the supervision of a coloproctologist, surgeon, or pediatric surgeon

· in the absence of indications for further inpatient treatment

· if the patient needs to be transferred to another medical institution

· at the request of the patient or their legal representative

· in cases of non-compliance by the patient with prescriptions or internal inpatient rules, provided this does not threaten the life of the patient or the health of others.

7. Additional Information

Negative factors affecting treatment outcomes include:

1. Development of infectious complications.

2. Stool disorders (diarrhea or constipation).

3. Non-compliance by the patient with restrictions on physical activity and exertion.

Criteria for Evaluating the Quality of Medical Care

Criteria for evaluating the quality of primary health care provided to adults with acute paraproctitis

Criteria for evaluating the quality of specialized medical care provided to adults with acute paraproctitis

References

Appendix A1. Working Group Composition

All members of the working group are members of the Association of Coloproctologists of Russia. There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of the clinical guidelines:

1. Coloproctologists

2. Surgeons

3. Pediatric surgeons

4. Gastroenterologists

5. General physicians / Internists

6. General practitioners (family physicians)

7. Endoscopists

8. Mid-level medical professionals

9. Healthcare organizers

10. Expert physicians of medical insurance organizations (including when conducting medical and economic expertise)

11. Medical university students, residents, postgraduate students.

In these clinical guidelines, all data are ranked by level of reliability (evidence) depending on the quantity and quality of studies on the issue.

Table 1. Scale for grading levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for grading levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)

Table 3. Grading of grades of recommendations (GR) for preventive, diagnostic, therapeutic, and rehabilitation methods (interventions)

Procedure for updating clinical guidelines

The mechanism for updating clinical guidelines provides for systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Related documents

These clinical guidelines were developed taking into account the following regulatory legal documents:

1. Clause 3 of Article 37 of Federal Law No. 323-FZ of the Russian Federation dated November 21, 2011, “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” (as amended and supplemented, effective January 11, 2023);

2. Order of the Ministry of Health of the Russian Federation No. 203n dated May 10, 2017, “On Approval of Criteria for Assessing the Quality of Medical Care”;

3. Order of the Ministry of Health of the Russian Federation No. 206n dated April 2, 2010 (as amended on February 21, 2020) “On Approval of the Procedure for Providing Medical Care to the Population with Coloproctological Diseases of the Colon, Anal Canal, and Perineum”;

4. Order of the Russian Ministry of Health No. 71n dated February 11, 2022, "On Approval of the Standard of Medical Care for Adults with Acute Paraproctitis (Diagnosis and Treatment)".

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Acute paraproctitis is an acute purulent-inflammatory disease of the pararectal adipose tissue. Infection from the rectum via the anal gland ducts can rapidly spread into one of the pararectal spaces — subcutaneous (most commonly), ischioanal, pelvirectal, or retrorectal (very rarely).

The forms of acute paraproctitis are named after these spaces: submucosal, subcutaneous, ischioanal, pelvirectal (pelvirectal space abscess), and retrorectal. An intersphincteric abscess is sometimes distinguished, but this term is better used in chronic paraproctitis, as it is difficult to precisely localize the abscess cavity during an acute process. The internal opening of the abscess is almost always single, while there may be two or more external openings, and these external abscesses are often located on both sides of the anus — posteriorly or anteriorly to the rectum (horseshoe paraproctitis). The "arch" of such an abscess passes posteriorly, between the anus and the coccyx (most commonly) or anteriorly to the anus (in women, between the anus and the rectovaginal septum). Accordingly, posterior or anterior horseshoe acute paraproctitis is diagnosed, and the abscess may be subcutaneous on one side and ischioanal on the other, etc. Most commonly, in more than half of all patients, the abscess is located at the border of the skin and mucosa — subcutaneous-submucosal marginal acute paraproctitis.

The clinical presentation of acute paraproctitis is typical of any pararectal suppuration: swelling, tenderness upon palpation, pain that is increasing or sometimes sudden, worsening with walking and sitting, coughing, or defecation (not always), and softening in the center. General condition worsens, and low-grade fever appears. The general condition suffers most with deep (ischioanal, pelvirectal) abscesses, while local changes in these forms of abscess are minimal — there is almost no skin redness, and only deep thrusting with the fingertips elicits pain on the affected side.

With deep (high) ischioanal, pelvirectal, or retrorectal acute paraproctitis, the patient's general condition may be severe (high fever, all signs of intoxication, deep pelvic pain), while local changes may sometimes be unimpressive.

Anal fistulas frequently develop after drainage of acute paraproctitis.

The decision on whether to perform a specific radical surgery for acute paraproctitis should be made exclusively by a specialist coloproctologist. When such a patient is admitted to a general surgery department, the abscess in the perineum should simply be widely opened and drained, and the patient warned about the potential recurrence of the abscess or the formation of a rectal fistula. If this occurs, the patient should be referred for elective surgery to a coloproctology department.

Following abscess drainage, it is preferable to subsequently perform a qualified elective surgery for anal fistula in a coloproctology clinic rather than attempting by any means to radically operate on acute paraproctitis in a single stage without regard for the future function of the sphincter apparatus.

Complete recovery occurs with timely surgical treatment. In cases of inadequate drainage, lack of treatment, or chronic infection, a fistulous tract forms as a consequence of paraproctitis.

Sometimes fistulous tracts facilitate the spread of inflammation into hard-to-reach areas of the lesser pelvis. As a result, the infection becomes impossible to eliminate completely. This provokes constant recurrences of paraproctitis. A prolonged course of the disease can cause adhesive processes in the lesser pelvis and scarring changes in the walls of the anal canal.

Prevention consists of the timely treatment of rectal diseases and compliance with personal hygiene. Prompt surgical treatment of the acute phase of the disease prevents the formation of anal fistulas. An important factor in preventing the condition is the normalization of bowel function.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

No.