Management of retrorectal supralevator abscess—results
of a large cohort
Accepted: 22 May 2018
Springer-Verlag GmbH Germany, part of Springer Nature 2018
Purpose Proximal intersphincteric fistulas with proximal extension causing supralevatoric, retrorectal abscesses are a rare disease.
There is only very limited experience, with small groups, and the limited published literature confirms the complexity of diag-
nostics and treatment. The aim of this study was to evaluate transrectal internal abscess drainage as planned definitive treatment.
Methods We retrospectively studied medical records of all patients with the diagnosis of retrorectal abscesses that underwent
transrectal internal abscess drainage in the Department of Colo-proctology of the University Medical Centre Mannheim (2003–2012).
Results One hundred nine patients were operated on retrorectal abscesses, 70 (64.2%) men and 39 (35.8%) women. Mean age was
45.3 years (18–81). In 96 cases (88.1%), only a transrectal internal abscess drainage was performed as planned definitive treatment.
Primary healing occurred in 60 patients (62.5%). A second transrectal internal drainage procedure was necessary in 27 cases
(28.1%) to assure complete internal drainage. All secondary procedures led to subsequent healing. A combined surgical treatment
due to coexisting fistula tracts to the perianal skin or additional ischioanal abscesses was required in 13 patients (11.9%), and an
additional seton placement was performed. Nine patients (9.4%) underwent one or more reoperations due to previously uniden-
tified complex coexisting fistulas. Most of these patients were immunosuppressed due to Crohn’s disease. Internal drainage alone
was successful in 90.6% with an overall healing rate of 94.5% for the entire population of complex fistulas.
Conclusions Transrectal internal abscess drainage is a safe and highly successful procedure for treatment of retrorectal abscess,
with very low risk of postoperative fecal incontinence. Inflammatory bowel disease and immunosuppressives have a negative
impact on the healing process.
Keywords Transanal internal abscess drainage
Anal abscesses and fistulas are a common surgical condition.
The cryptoglandular theory of Eisenhammer and Parks is the
widely accepted pathophysiologic mechanism for development
of these fistulas [1, 2]. Abscesses can be classified as perianal,
ischiorectal, intersphincteric, and supralevator/retrorectal. In
1934, Milligan and Morgan and later Stelzner, as well as
Goligher and Eisenhammer, described initial classifications of
fistulas [3, 4]. Nowadays, the modified classification by Parks
published in 1976, based on the course of the fistula in relation
to the anal sphincters—inter-, trans-, supra-, and
extrasphincteric—is the most widely used and accepted .
Management of the majority of anal abscesses and fistulas is
straightforward and is based on the knowledge of the anatomy
of the anorectum and adherence to establish surgical principles.
In most of the cases, adequate surgical drainage is sufficient,
reliable, safe, and feasible. On the contrary, intersphincteric
abscesses can be difficult to diagnose. The usual external clin-
ical signs of perirectal abscesses, such as swelling and indura-
tion of the perianal region, may not be present [6–8]. The ma-
jority of these fistulas track distally and are also fairly easily
managed with typical surgical strategies. Proximal extension
Patrick Téoule and Steffen Seyfried contributed equally to this work.
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s00384-018-3094-7) contains supplementary
material, which is available to authorized users.
* Patrick Téoule
Department of Surgery, University Medical Centre Mannheim,
Medical Faculty Mannheim, Heidelberg University,
Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
Deutsches End- und Dickdarmzentrum, Mannheim, Germany
International Journal of Colorectal Disease