Where does pus come from?
In the anal canal, at the border of the skin and mucous membrane, there are crypts - small pockets into which the ducts of the anal glands open. If the duct is blocked, the contents of the intestine stagnate in the gland and suppuration begins. The pus seeks a way out and spreads through the loose fatty tissue around the rectum, along the path of least resistance. This is how a cavity is formed, and the passage from the affected crypt to this cavity remains an internal opening - it is because of this that a fistula is formed in some patients after opening.
An important distinction follows from this mechanism. Paraproctitis is similar in appearance to an ordinary skin boil, but is structured fundamentally differently: the skin abscess opens superficially and heals in a few days, while the pararectal one is connected to the intestinal lumen and has a constant source of infection as long as this connection exists. The difference determines both the scope of the operation and the prognosis: after a boil, a fistula does not remain, but after paraproctitis, it is quite possible. Therefore, any abscess in the anus should be examined by a coloproctologist or surgeon, and not treated at home by analogy with inflammation on the skin.
- Anal fissure and chronic hemorrhoids - constant microtrauma of the mucous membrane
- Constipation and injury to the intestinal wall with dense feces
- Prolonged diarrhea and irritation of the perineal skin
- Diabetes mellitus and any immunocompromised conditions
- Crohn's disease and other inflammatory bowel diseases
- Perineal injuries, foreign bodies, consequences of interventions in this area
- Hypothermia and prolonged sitting as a provoking, but not the main factor
The listed factors also explain the distribution of morbidity: paraproctitis is more common in men of working age, and in people with diabetes it is more severe and less treatable. In this case, the patient often does not have any of the listed prerequisites at all - blockage of the anal gland duct can occur for no apparent reason. Therefore, the question “what did I do wrong” in most cases has no answer, and there is no point in looking for someone to blame for hypothermia or what was eaten the day before.
Forms: why symptoms are so different
The clinical picture depends on the space in which the pus has accumulated. This also determines whether something will be noticeable from the outside.
- Subcutaneous - the most common and most “understandable”: a dense, painful formation appears near the anus, the skin above it turns red and becomes hot
- Submucosal - located in the intestinal wall, almost invisible from the outside, causing pain during bowel movements and the feeling of a foreign body
- Ischiorectal (ischiorectal) - pus in the deep cellular space; there is only slight swelling on the outside at first, but the temperature and pain are very pronounced
- Pelviorectal (pelviorectal) is the most insidious: there may be no external signs at all, but high fever, chills, pain in the lower abdomen and pelvis come to the fore
- Retrorectal - pain behind the rectum, radiating to the coccyx and sacrum, often first treated as “pain in the coccyx”
The speed of development of forms is also different. Subcutaneous paraproctitis develops in 2-3 days and forces you to seek help. Deep forms can grow for a week or longer, giving a blurred picture of “incomprehensible temperature with heaviness in the pelvis,” and it is they who more often end in complications - simply because the diagnosis is made later. Therefore, in case of unexplained fever combined with pain or discomfort in the perineum, an examination by a coloproctologist should be included in the examination plan immediately, and not left for later.
How it manifests itself in the first days
Paraproctitis develops quickly, and this is one of its main differences from chronic proctological diseases, to which people get used to over the years. Here the count is days, and sometimes even hours, so it is useful to imagine the sequence of events: it is recognizable and allows you to understand at what stage the situation is and how much time has already been lost.
- Первые сутки: нарастающая боль в области заднего прохода, поначалу тупая, затем пульсирующая, усиливающаяся при движении и дефекации.
- Вторые-третьи сутки: температура поднимается до 38 и выше, появляются озноб, слабость, головная боль, пропадает аппетит.
- Дальше: боль становится непереносимой, невозможно сидеть, спать удаётся только в вынужденной позе, при поверхностной форме появляется плотное горячее выпячивание.
- Если гнойник прорывается сам — наружу или в просвет кишки — боль резко стихает и появляется гнойное отделяемое. Кажется, что «всё прошло», но полость дренировалась не полностью, и процесс переходит в хронический.
Spontaneous breakthrough of an abscess is not a recovery, but the most common scenario for the formation of a fistula. That is why relief after a “breakthrough” is not a reason to cancel a visit to the doctor: it is still necessary to examine and evaluate what remains inside.
What not to do: warming up, baths and antibiotics “just in case”
This is the most common and most expensive mistake in terms of consequences. The advice “take a steam bath, apply a heating pad, sit in a hot bath” sounds logical - heat really reduces pain for an hour or two. But heat dilates blood vessels and accelerates the spread of pus through the tissue, and pain relief masks the deterioration. People who have been warming themselves for three days are admitted for surgery with an abscess many times larger in volume.
- Heating pads, hot baths, “warming up” with salt or alcohol compresses - the purulent process spreads faster
- Ointments and suppositories instead of surgery - the active substance does not reach the purulent cavity deep in the tissue
- Antibiotics without opening - they can bring down the temperature and erase the picture, but the cavity with pus remains in place
- Attempting to squeeze out or puncture an abscess on your own is a direct path to spreading the infection.
- Waiting “until it breaks through on its own” usually ends in a fistula or widespread inflammation
Painkillers deserve a separate discussion. Taking the drug to wait until you see a doctor is reasonable and correct. But taking it to continue going to work and not seeking help is dangerous: it extinguishes exactly the signal by which the severity of the process is assessed. The guideline is simple - if after taking the pain the pain returns a few hours later and becomes stronger than before, this is a sign of progression, and not a reason to increase the dose or change the drug.
Diagnosis and surgery
The diagnosis in most cases is made by examination and digital examination of the rectum - the doctor determines both the abscess itself and, more importantly, the affected crypt. With deep forms, visualization is activated.
- Осмотр и пальцевое исследование прямой кишки — базовый и наиболее информативный этап.
- УЗИ мягких тканей промежности либо трансректальное УЗИ — показывает размеры и границы полости.
- МРТ малого таза — при глубоких, рецидивирующих и сложных формах, когда нужно точно понять ход гнойных затёков.
- Общий анализ крови, глюкоза крови — оценка выраженности воспаления и выявление недиагностированного диабета.
- Операция: вскрытие полости, эвакуация гноя, промывание, дренирование. Обязательно оценивается связь с просветом кишки.
The scope of the operation is determined by the surgeon depending on the situation. Sometimes it is enough to open and drain the abscess, and solve the issue with the internal hole in the second stage, after the inflammation has subsided. In other cases, a one-step intervention with the elimination of the affected crypt is possible. The choice depends on the shape, depth, relationship of the stroke to the sphincter muscle and the patient’s condition - the task is not only to remove pus, but also not to damage the retention mechanism.
The issue of pain relief is decided individually: the autopsy is performed under spinal anesthesia or intravenous anesthesia; local anesthesia for severe purulent inflammation is usually not enough, and it will have a worse effect in inflamed tissues. Hospitalization is often short, but for severe forms, in patients with diabetes and with widespread inflammation, hospital observation is extended. Separately, during the examination, the blood glucose level is assessed: often it is paraproctitis that becomes the reason for which diabetes mellitus is detected for the first time, and without its compensation the wound heals noticeably worse.
After surgery and why the fistula remains
- Рана заживает вторичным натяжением, то есть открытой, снизу вверх — это правильно и предотвращает повторное скопление гноя. Полное заживление занимает в среднем от 3 до 6 недель.
- Перевязки первое время делают ежедневно; ключевое условие — чистота раны и отсутствие «слипания» краёв раньше времени.
- Стул должен быть мягким и регулярным: питьевой режим, клетчатка, при необходимости мягкие слабительные по назначению врача.
- Подмывание прохладной или тёплой водой после каждой дефекации; сидячие ванночки — только если их назначил врач и только после операции, а не до неё.
- Возврат к работе обычно возможен через 1–3 недели в зависимости от объёма вмешательства, тяжёлые физические нагрузки откладывают.
The pain after opening is usually significantly less than what it was before the operation: the source of pressure in the closed cavity has been removed. The doctor prescribes pain relief in the first days, and there is no need to endure pain - it interferes with normal bowel movements, and stool retention impairs wound healing. The first stool after surgery is not deliberately postponed: on the contrary, they achieve its soft consistency in advance so that it does not injure the wound. Fear before going to the toilet for the first time is a typical and completely solvable problem that should be told to the doctor before discharge, rather than tolerated at home.
