Pelvirectal Abscess

Aka: Pelvirectal Abscess, Supralevator Abscess

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II. Epidemiology

  1. Uncommon (represents only 5% of Anorectal Abscesses)

III. Pathophysiology

  1. Infection begins at the perianal crypts along the Dentate Line and spreads via the intersphincteric groove
  2. Infection may also spread from an intraabdominal source (e.g. perforated colon)
  3. Perirectal Abscess spread to above levator ani Muscle

IV. Causes

  1. Pelvic Inflammatory Disease
  2. Diverticulitis
  3. Ruptured Appendicitis

V. Symptoms

  1. Rectal Pain (esp. with stooling)
  2. Urinary tract symptoms
  3. Urinary Retention
  4. Back Pain (referred pain from sacral nerve inflammation or compression)

VI. Signs

  1. Fever
  2. Tender, fluctuant mass may be present above the anorectal ring on Digital Rectal Exam
  3. External exam is typically unremarkable

VII. Differential Diagnosis

  1. High Ischiorectal Abscess
  2. Intersphincteric Abscess

VIII. Imaging

  1. CT Pelvis

IX. Labs

  1. Complete Blood Count: Leukocytosis

X. Diagnosis: Rectal mucosa fullness on diagnostic testing

  1. Flexible Sigmoidoscopy or Colonoscopy
  2. Barium Enema

XI. Management

  1. See Perirectal Abscess
  2. Colorectal surgery or General Surgery Consultation
    1. Ischiorectal Abscess extending into the Supralevator Space
      1. Drain as with Ischiorectal Abscess via skin access
    2. Intersphincteric Abscess extending into the Supralevator Space
      1. Internal sphincterotomy through incision in the anal mucosa (as with Intersphincteric Abscess)

XII. References

  1. Marx (2002) Rosen's Emergency Medicine, p. 1952
  2. Roberts (1998) Procedures, Saunders, p. 649-51
  3. Sherman, Bahga and Vietvuong (2022) Crit Dec Emerg Med 36(7): 23-9

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