Perianal abscess

　　Western medicine believes that the cause of perianal abscesses is due to anal gland infection. Clinically, 99% of anal abscesses are closely related to anal gland infection and suppuration. Some are caused by infection from anal fissures, where bacteria enter the subcutaneous tissue through the crack to form abscesses. A few are due to untreated or misdiagnosed infections from anal follicles, cysts, or trauma.

　　Traditional Chinese medicine believes that for those with实证, it is often due to irregular diet, overeating of spicy and greasy foods, leading to endogenous damp-heat, accumulation of heat-toxin, or due to skin damage, infection with toxic evil, blood stasis, meridian blockage, and corruption of flesh and blood. For those with虚证, it is often due to deficiencies in the lung, spleen, and kidney, with damp-heat descending to the anal area. This disease is more common in young and middle-aged adults aged 20-40, with intensity and incidence rate depending on the season, region, and population. The pathogenesis of肛痈 is due to overeating of fatty and spicy foods, downward invasion of damp-heat, or condensation of phlegm-damp, with evil toxins remaining in the anal and rectal area, leading to blood stasis, corruption of heat-toxin into pus, and formation of abscess.

　　Improper treatment of perianal abscesses can easily lead to anal fistulas and cause cellulitis of the anal and rectal area, especially deep cellulitis, which is a relatively serious problem. Sometimes it can spread to the perineum, inguinal area, and lower abdomen; sometimes it can cause sepsis, leading to loss of life. Early treatment is recommended to prevent spread.

　　1. Infection and pus discharge:Once an anal fistula forms, the chance of spontaneous healing is rare, and it brings a series of harms. Firstly, after anal fistula infection and inflammation, anal pain is severe, and after ulceration, pus pollutes the underwear. The pus stimulates the local skin, causing severe anal itching. Over time, it can lead to emaciation, lack of energy, decreased resistance to disease, and more frequent attacks, forming a reciprocal causation.

　　2. Increase in fistula orifice and fistula tube:Repeated episodes of anal fistulas can cause pus to penetrate the wall of the tube and spread along the anal sphincter spaces, forming multiple and complex anal fistulas. Not only does this make treatment difficult, but it also affects the physiological function of the anal area.

　　3. Anal incontinence:Allowing an anal fistula to progress can cause severe damage to the anal sphincter, and even possibly lead to complications such as anal incontinence.

　　4. Risk of malignancy:The multifocality of anal fistulas can lead to rectovaginal fistulas, rectourethral fistulas, and rectovesical fistulas, threatening surrounding organs, and old anal fistulas that have not been treated or misdiagnosed may have a risk of cancerous transformation.

　　1. Local redness, swelling, heat, and pain around the anal area, with an acute onset and rapid progression of the disease. It may include systemic symptoms such as chills, fever, decreased appetite, dry stools, dark urine, and dry mouth.

　　2. The specific manifestations of anal perianal abscesses vary depending on the location of the abscess around the rectum:

　　(1) Anal subcutaneous abscess: Anal pain, initially persistent, then becoming jumping pain, coughing, walking, and defecation can exacerbate the pain. On examination, redness and swelling are observed around the anal area, with tenderness. If pus has formed, it has a fluctuant sensation when pressed, with mild systemic symptoms.

　　(2) Ischiorectal pouch abscess: Initially, there may be discomfort or mild pain in the anal area, gradually accompanied by fever, aversion to cold, headache, loss of appetite, and other systemic symptoms. Then, local symptoms become more severe, with burning or jumping pain in the anal area. A tender bulge can be felt in the ischiorectal pouch on the affected side during rectal examination.

　　(3) Pelvic rectal interspace abscess: Initially, there may be fever, chills, and general malaise. Then, there is a feeling of weight in the rectum, often wanting to defecate, discomfort and pain in the anal area during defecation, and sometimes difficulty in urination or urinary retention. A bulge with tenderness and fluctuation can be felt on the affected side of the rectal wall during rectal examination.

　　(4) Submucosal rectal abscess: Initially, there may be a feeling of weight or fullness in the rectum, followed by dull or jumping pain, which worsens during defecation, fever, headache, and general weakness. A round fluctuating mass can be felt on the rectal wall during rectal examination.

　　(5) Posterior rectal interspace abscess: Initially, there may be chills and fever, a feeling of weight in the rectum and anal area, and dull pain in the sacral tail that radiates downward. A hard mass can be felt after rectal examination, or there may be fluctuation.

　　Perianal abscess refers to suppurative diseases formed by the infection of soft tissues around the anal rectum. The symptoms of perianal abscess have a significant impact on people's work and life. Therefore, developing regular and smooth defecation and good hygiene habits are powerful measures for prevention.

　　1, Hemoglobin and red blood cell count.

　　Mainly reflects the degree and nature of the patient's anemia and can also be used as one of the criteria for determining whether blood transfusion is needed.

　　2, Platelet count and coagulation time.

　　Routine preoperative examination is indispensable, and it is of great significance for distinguishing the nature of hemorrhage.

　　3, White blood cell count and classification.

　　An increased white blood cell count indicates that the body's defense response against pathogenic damage is enhanced, which is a normal phenomenon in most inflammatory processes. A decreased white blood cell count is common in cases caused by drugs such as chloramphenicol or radiation substances such as X-rays.

　　4, Stool routine.

　　Including gross observation of fecal shape, hardness, color, blood presence, smell, microscopic examination, and bacteriological examination.

　　5, Urinalysis.

　　Including urine volume, specific gravity, color, urine protein, urine sugar, acid-base reaction, and microscopic examination, etc. When a patient has massive bleeding causing hemorrhagic shock, the doctor needs to guide fluid resuscitation according to the changes in urine volume and urine specific gravity.

　　6, Biochemical examination.

　　When examining anorectal diseases, it is sometimes necessary to exclude other disease factors, such as heart disease, kidney disease, liver disease, and so on.

　　Patients with perianal abscess should mainly consume light and easily digestible foods. It is forbidden to eat fishy, spicy, and刺激性 foods. If the diet is not appropriate, it can lead to constipation, and the dry and hard feces can tear the anal valves and injure the anal skin and mucosa, making it easy for bacteria to enter the perianal tissue through the wound and cause infection, forming an abscess. Therefore, it is necessary to eat more fibrous foods such as sweet potatoes, celery, eggplant, bananas, corn, and so on in daily life. Adjusting the diet to prevent constipation and maintain smooth defecation will be beneficial to the recovery of the disease.

　　The treatment of early rectal perianal abscess with traditional Chinese medicine is mostly due to实证 and 热证, and the treatment should be clearing heat and detoxifying, cooling blood and removing blood stasis, softening hardness and dissipating nodules, mainly using the method of eliminating; in the middle stage, when pus has formed and evil remains, the treatment should be reinforcing the body and expelling toxins, mainly using the method of expelling; in the late stage, when toxins are exhausted and the body is weak, the treatment should be tonifying Qi and blood, invigorating the spleen and permeating dampness, nourishing the liver and kidney, mainly using the method of tonifying. As mentioned in 'Comprehensive Treatise on External Diseases – General Treatise on the Treatment of Sores and Abscesses': 'In the early stage, examine the symptoms and eliminate them; in the stage of pus formation, follow the trend and expel it; in the stage of toxin exhaustion, reinforce what is insufficient and condense it, this is the main principle of treating sores.' Therefore, in clinical practice, attention should be paid to both internal and external treatment, and both the whole and the local should be emphasized for differential diagnosis and treatment.

　　First, differential diagnosis and prescription selection:

　　1. Accumulation of Fire and Toxin:

　　Treatment: clearing excess heat and promoting the dispersal of stagnation. Prescription: modified Neishu Huanglian Decoction. Huanglian 10 grams, Huangqin 6 grams, Dahuang 6 grams, Zhizi 10 grams, Jiegeng 6 grams, Muxiang 6 grams, Binglang 6 grams, Lianqiao 10 grams, Chishao 10 grams, Baishao 10 grams, Danggui 10 grams, Gancao 6 grams. Add Yuanhu for severe pain; add Hemaran for constipation.

　　2. Exuberant Heat and Toxin:

　　Treatment: reducing swelling and dissipating nodules, promoting blood circulation and removing blood stasis to relieve pain. Prescription: modified Xianfang Huoming Decoction. Chuanshanjie 10 grams, Zaojiaoci 10 grams, Dangguiwei 12 grams, Jingyinhua 12 grams, Chishao 12 grams, Ruixiang 10 grams, Maima 10 grams, Tianhuafen 12 grams, Chenpi 6 grams, Fangfeng 6 grams, Baizhi 6 grams, Gancao 6 grams. Add Yuanhu for severe pain; add Hemaran for constipation.

　　3. Anorectal Damp-Heat Syndrome:

　　Treatment: clearing heat and removing dampness. Prescription: modified Qingre Chushi Decoction.

　　4. Persistent Yin Deficiency and Toxin Retention:

　　Treatment: nourishing Yin and clearing heat, removing dampness and softening hardness. Prescription: modified Ziyin Chushi Decoction. Chuanxiong 10 grams, Danggui 12 grams, Baishao 12 grams, Shudihuang 12 grams, Chaihu 6 grams, Huangqin 9 grams, Chenpi 9 grams, Baimu 10 grams, Diguipi 10 grams, Zexie 10 grams, Gancao 6 grams. Add Huangqi for Qi deficiency; add Maidong for severe dry mouth; add Hemaran for constipation; add Dahuang.

　　5. Deficiency of both Qi and blood:

　　Treatment: tonifying Qi and blood. Prescription: modified Baizhen Decoction.