A 30-year-old male presents with severe throbbing perianal pain that is constant, worse with sitting and coughing, and accompanied by fever. Physical exam reveals a fluctuant, exquisitely tender, erythematous swelling in the perianal region. What is the appropriate management?

Answer and explanation

Correct answer: B. Immediate incision and drainage under local or regional anesthesia

  1. Step 1: The patient presents with an acute perianal abscess originating from infected anal cryptoglandular crypts.
  2. Step 2: Antibiotics alone cannot penetrate an enclosed purulent collection and fail to prevent tissue necrosis.
  3. Step 3: The definitive treatment is prompt surgical incision and drainage to relieve pain and prevent fistula-in-ano or necrotizing fasciitis (Fournier's gangrene).
  4. Step 4: Identify immediate incision and drainage.
Answer
Immediate incision and drainage under local or regional anesthesia.
Why not the others: 'Oral antibiotics and sitz baths alone' cannot drain enclosed pus; 'Topical hydrocortisone' is for hemorrhoids or pruritus and immunosuppresses infected tissue; 'Colonoscopy' is contraindicated in acute painful perianal infection.

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