Interestingly, these were not just small cutaneous abscesses but rather large ones that were often treated under general anesthesia in the OR. An abscess of the perianal region would give many clinicians hesitation for primary closing. It appears, however, that if you have your perirectal abscess drained in Nigeria or India, you will have it sutured closed immediately after drainage. Not only does primary closure not result in significant complications, it provides faster healing and a similar abscess recurrent rate with secondary closure. To be fair, however, others have reported failure of this intervention, perhaps one reason why it has not been universally adopted. (Br J Surg 1977;64:264.)
The next axioms that should be investigated are the need for irrigation and breaking up loculations. Many clinicians will meticulously irrigate an abscess cavity with saline, but this technique also has not been standardized or studied. I personally rarely irrigate an abscess cavity, but will evacuate necrotic or purulent tissue with dry 4 × 4 gauze. If pus is copious, I will initially pack and replace the packing with new gauze 10 to 15 minutes prior to discharge, hopefully before the anesthetic has worn off.
Most patients cannot deal with their own packing removal or packing changes at home, but I have occasionally instructed patients to remove the packing in 48 hours, clean out the cavity with a cotton tip containing peroxide, and to hold the skin open in the shower to clean the abscess cavity further, negating a repeat ED visit. When to stop packing or ideal packing intervals are also variable interventions. Traditionally packing is every two or three days and halted on the first visit that contains a relatively dry pack.
Irrigating an abscess cavity is relatively easy, likely impresses the patient (the show business of emergency medicine), and other than perhaps being a bit messy, it seems reasonable. Packing material is not standardized. I pack a large abscess with a few 4 × 4s or plain gauze strips. Iodinated gauze packing gives that comforting antiseptic smell and may sting a bit, but it has no proven advantage. I also presoak the packing in saline or betadine prior to packing because it is easier to place when wet.
If one is going to break up loculations, an easy way is to wrap some gauze around the hemostat and swirl it around the base of the abscess. Traditionally, surgeons have used their finger, and that's not a bad idea as long as you are sure there are no sharp objects that could cut you. Using your finger does give you an idea of the depth of the cavity, and the tactile sensation allows you to get into every nook and cranny (but it really hurts!).
UpToDate.com recommends probing the abscess cavity with a hemostat to “ensure proper drainage” and to irrigate the abscess cavity copiously with isotonic saline until all visible pus is removed. UpToDate also suggests packing abscesses greater than 5 cm in diameter, pilonidal cysts, or those in immunocompromised or diabetic patients. This is the only source I have come across that has a special recommendation for packing in immunocompromised or diabetic patients. I am certain no study supports this recommendation, and I will wager that packing has no special curative properties for this subset of patients.
Evidence-Based Approach to Abscess Management
Korownyk C, Allan GM
Can Fam Physician
The authors in this rather ambitious attempt to analyze evidence-based treatment of cutaneous abscesses searched PubMed, the Cochrane Library, and Google for the past 50 years, looking for the scientific basis for treatments of cutaneous/soft tissue infections. A lack of randomized controlled trials and little evidence-based data emerged.
The authors could find no scientific basis evaluating optimal pain control for I&D. Some patients described abscess drainage as one of the most painful procedures in the ED, despite the use of local anesthetics. Local anesthesia certainly helps, but it does not make the procedure totally pain-free. Of course, the effectiveness of any local anesthetic depends on the skill and expertise of the clinician, and one should be initially generous and repeat the local anesthesia if needed. No evidence exists for simply using vapocoolant sprays in managing abscesses.
It would be heinous not to provide local anesthesia for the skin incision. Many will stop here, but more can be done. A frequently forgotten technique is to inject through the cut edge of the opened abscess and into the soft tissue prior to further manipulation. The local skin incision should probably be painless, but abscess manipulation hurts unless one provides either a field block or anesthesia deeper into the abscess itself.
I am continually amazed by the neophyte clinician who believes that 1 mg Dilaudid IM about 20 minutes before I&D defines analgesia. Adjunct parenteral analgesics are fine, but are usually only helpful if they are given IV and in generous doses. Only a novice clinician believes that an IM dose of an analgesic is worth the time and effort prior to incising an abscess. Conscious sedation is probably the best way to go for larger cases (my favorite is ketofol), but most clinicians don't take the time or effort to do this.
Ideally, a large abscess should be drained under general anesthesia, but the surgical staff is always reluctant. If I am calling a surgeon for help with an abscess, the patient needs to be admitted or drained in the OR, not simply sliced open by a consultant who is totally uninterested in this mundane case or has just been sprung from an interesting case in the OR to aid the struggling emergency physician.
These authors conclude that no evidence beyond expert opinion and tradition support any of the currently performed rituals for I&D or post-operative care. Despite no real evidence, these authors and most clinicians continue to recommend irrigation, breaking loculations, and packing following I&D. These authors do not recommend primary closure; apparently they were not trained in Europe. This article seems to incorporate most of our current clinical practice, unproven bias, and the overall that's-the-way-we-do-it mentality under the guise of “evidence-based.”
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Dear Dr. Roberts: I have questions for you regarding your articles on gonorrhea and chlamydia. (“Neisseria Gonorrhoeae: The New Superbug,” EMN 2012;34:10; 2012;34:12; 2012;34:10.) Why do you think the accuracy or sensitivity for GC urine testing is different between men and women? What is the difference in sensitivity between the sexes? How does one justify treating for GC and chlamydia without testing or symptoms unless the prevalence of these diseases is very high? Indiscriminate use of antibiotics, I thought, was inappropriate because of the increase risk of resistance. Thank you. — Marcus Ma, MD, Temperance, MI
Dr. Roberts responds: To review, a urethral swab performs well for testing for suspected GC/Chlamydia urethritis in men, but nucleic acid amplification testing of urine is the preferred method if a noninvasive test is desired. Nucleic acid amplification testing of a vaginal swab specimen has the best overall sensitivity and specificity for women with suspected cervicitis or urethritis. The test will likely pick it up equally, regardless of gender, if the bug is in the urine.
One likely reason the vaginal swab is preferred is that the cervix, not the urethra, can be the primary infected site, and therefore the urethral urine may not be subject to organism inoculation. If it's in the urine, likely it's in the cervix, but not the other way around.
For isolated urethritis, the urine test is likely adequate for women, but it's best to test the reservoir site. Regarding treatment without testing or symptoms, I assume you are referring to treating contacts empirically. That has always been the recommendation to avoid further spread, but it's often difficult and certainly does have the potential to increase resistance, and maybe it has. Resistance vs. curing asymptomatic infection is a tradeoff; you can be the judge of the risks and benefits. The prevalence of the infection in a sexual contact is by definition, however, high, hence empiric treatment is justified by at least the CDC.© 2013 Lippincott Williams & Wilkins, Inc.