Secondary Healing of Horseshoe Perianal Abscess in a Patient With Morbid Obesity

Experience at a Rural Hospital

Fidkya Allisha, S.Ked; Gideon Setiawan, SpB; Reno Rudiman, SpB-KBD, MSc; Vita Indriasari, SpBA(K), M.Kes


Wounds. 2022;34(8):e57-e62. 

In This Article

Abstract and Introduction


Introduction: Perianal abscess is defined as a local collection of pus in the perianal tissues. It is among the most common anorectal problems encountered by surgeons. Further extension of this infection into the unilateral or bilateral ischiorectal fossa leads to a horseshoe abscess. Morbid obesity is a risk factor for horseshoe perianal abscess with the potential to disrupt the normal healing process.

Case Report: A 35-year-old male with morbid obesity presented to the surgery outpatient clinic in a hospital in Subang, West Java, Indonesia, with continuous severe pain and swelling around the anus of approximately 7 days' duration. Local examination of the anogenital area revealed a horseshoe perianal abscess extending to the ischiorectal fossa, approximately 1 cm from the anal verge and measuring 7.5 cm × 4.5 cm × 10 cm. Physical examination findings included tenderness to palpation; the presence of blood, pus, and necrotic tissue; and fluctuance. Incision and drainage were performed in the operating room under general anesthesia. In lieu of colostomy, the patient chose wound healing by secondary intention. Postoperative open wound care consisted of wet-to-moist gauze dressings during the first 2 postoperative days, followed by hydrocolloid dressing after the pus and blood were adequately drained, and finally, alginate dressing after granulation tissue formed. Aluminum silicate (microporous ceramic) was used as the external (secondary) wound dressing. Time to healing was 8 weeks.

Conclusion: Horseshoe abscesses are challenging to manage. Thorough and careful diagnosis, prompt fluid resuscitation to overcome fluid and electrolyte imbalance and to ensure proper antibiotic administration, nutrition intake, and a planned surgical approach as well as individualized postoperative care are necessary to achieve healing.


Perianal abscess is a local collection of pus in the perianal tissues, and it is among the most common anorectal problems encountered by surgeons. The most frequent etiology is glandular infection arising from the anal crypts, and perianal abscess is associated with anal fistula in approximately 40% of cases.[1] According to Sahnan et al,[2] 90% of perianal abscesses are caused by cryptoglandular infection. The remaining 10% are the result of etiology other than anal gland infection, such as Crohn disease, tuberculosis, trauma, chronic inflammation, hidradenitis suppurativa, HIV, sexually transmitted diseases, radiotherapy, malignancy, and foreign bodies.[3,4] Further extension of this infection into the unilateral or bilateral ischiorectal fossa through the conjoint longitudinal muscle in the anterior or posterior midline, or through the deep anterior or posterior anal space, leads to a horseshoe abscess.[5]

Perianal abscess is one of the most common anorectal diseases that occurs in males aged 30 to 50 years.[5] The incidence is 16.1 to 20.2 per 100 000 per year, and the rate of subsequent fistula formation following an abscess is 15.5%.[2,6] Perianal abscess may spread alongside the rectum (ischiorectal), above the pelvic floor (supralevator), or between the muscles of the anal canal (intersphincteric).[7]

If the perianal abscess is not drained spontaneously or surgically, the infection may spread rapidly and result in extensive tissue loss. Even if the abscess is drained, fistula-in-ano may occur.[6] The goal of surgical management of anal fistula is to eradicate sepsis and promote healing of the tract while preserving the sphincters and the mechanism of continence; surgery is also performed to prevent recurrence.[8] Management of fistula-in-ano remains challenging.[5,8]

The authors' experience of managing a case of horseshoe perianal abscess with secondary healing process in a 35-year-old male with morbid obesity is reported to broaden the knowledge and perspective of diagnosis and management of an extending perianal abscess.