106 Transrectal Abscess Drainage

Clinical Presentation

A 15-year-old male returns to the hospital 7 days following surgery for appendicitis with lower abdominal pain, diarrhea, dysuria, and fever. On examination, he has a tender lower abdomen with faint bowel sounds. On rectal examination, a mass is felt anterior to the rectum. Ultrasonographic examination reveals a collection deep in the pelvis. The patient is referred to a tertiary care center for further management. How should the collection be drained?

Figure 106A

Figure 106B

Radiologic Findings

Ultrasonography demonstrated a hypoechoic collection posterior to the bladder and anterior to the rectum with some debris within it (Fig. 106A). CT confirmed a deep pelvic abscess with an enhancing rim and small anterior air/fluid level. No other collections were identified (Fig. 106B).

Diagnosis

Postsurgical deep pelvic abscess requiring transrectal abcess drainage

Discussion

Background

Pelvic abscesses are often located deep within the pelvis and are surrounded by overlying bowel, urinary bladder, pelvic vessels, and bones, thus preventing a safe percutaneous transabdominal approach. The main advantage of a transrectal approach is that it provides a shorter and more direct path to the collection. The risk of injuring or contaminating adjacent structures is therefore reduced.

Etiology

The most common causes of a pelvic abscess include appendicitis and following surgery, often postappendectomy (the appendix may or may not have ruptured). Other less common causes may include underlying inflammatory bowel disease, pelvic inflammatory disease, or perforation as a consequence of neoplasm.

Clinical Findings

The typical postoperative abscess occurs in a patient who had an appendectomy 7 to 10 days prior and now has abdominal pain and fever. This scenario is the most common cause of pelvic abscess in the pediatric population.

Indications

A deep pelvic collection that does not have a safe percutaneous transabdominal access route as assessed by pre-procedural imaging
This can be due to a collection that is obscured by overlying bowel, pelvic vessels, and organs.
This technique can also be used to drain multiple collections.