It is not known exactly why perianal abscesses and fistulas occur. There are glands just above the anal canal that allow the stool to come out slippery. If these glands are deeply located and their canals are too thin, they can become infected due to obstructed canals. The infection can turn into an abscess, and if this abscess drains out of the skin near the anus, a canal can form between the skin and these glands. When the inner surface of the canal is covered with cells, it can become permanent. There are also authors claiming that perianal abscess is transmitted from the skin due to poor hygiene.
First, redness and tenderness develop on the anus edge. Then gradually abscess begins to form. Mild cellulite that develops in the tissue around the abscess causes restlessness and fever. If the treatment is not started at this stage, the accumulated pus spontaneously drains out of the skin and a relief occurs in the complaints. When the treatment is started, it either regresses on its own, or it empties spontaneously, or it is emptied by the doctor. We do not know exactly how much of perianal abscesses turn into perianal fistula. There are manuscripts stating that they can turn into fistula from 20% to 80%. As I have mentioned, it is said that fistula may be less in abscesses transmitted through the skin, since there is no connection with the inner part of the anus. We do not know which abscess is caused by the skin and which abscess is caused by the inflammation of the lubricating glands.
Families see something like a pimple head where the abscess is drained or evacuated. This pimple head dries up and crusts, then the crust falls off and 1-2 drops of pus flow from under it. Then it dries up again. This cycle repeats every 10-14 days on average. Some authors state that this condition, which is called as fistula, may disappear spontaneously before the age of 1.
The treatment of perianal abscess and fistula in babies is not clear. Generally, paediatricians and paediatric surgeons apply conservative or surgical treatment based on their personal experiences. Conservative treatment means local wound care, sitting baths, antibacterial ointments, hygiene and, if necessary, systemic antibiotics. Recently, some new agents have also started to be used locally (such as basic fibroblast growth factor bFGF, Ginseng and Tang- kuci Ten compound (GTTC)). When it comes to surgical treatment, the options are abscess drainage, fistulotomy, fistulectomy, seton placement.
Current evidence shows that abscess and fistula are a condition that can pass spontaneously in babies, and conservative treatment is recommended to be tried first. However, since drainage has a quicker symptom relief role for perianal abscess, surgical drainage is performed in many centres rather than waiting for spontaneous discharge.
In a study, it was reported that the possibility of subsequent fistula development in case of surgical evacuation of perianal abscesses is higher than conservative treatment. For this age group, sitting baths, hygiene and antibiotics seem more meaningful instead of surgical drainage in perianal abscesses in babies. Even if it is necessary to drainage, it should be done under general anaesthesia, if there is no pus coming from the anus or if there is no recurrent abscess, one should not be dealing with searching for fistula.
I want to emphasise again, there are publications showing that fistulas that develop in young babies can pass spontaneously in an average of 6 months. Therefore, conservative treatment must be applied first. If the fistula does not pass, it is recommended to do first fistulotomy, in other words, to open the front of the canal and scrap the cells inside. If the fistula recurs and becomes complicated, then fistulectomy, in other words complete removal of the fistule, may be more appropriate.
The situation is a little different for children older than a year. It may be necessary to consider inflammatory bowel diseases in older children, and if there is such a situation, it may be necessary to use drugs such as tacrolismus. This is a subject that needs to be explained with a different title.
In conclusion, perianal abscess and perianal fistula are very common in babies but can resolve spontaneously. The first approach specific to this age group should be conservative treatment option. Surgical approach is more prominent in older children, as it is similar to perianal sepsis in adults.
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