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Incision and Drainage

David E. Manthey, MD

Key Points

• Incision and drainage is the procedure of choice for

subcutaneous abscesses.

• Antibiotics are not necessary unless there is associated

cellulitis.

INDICATIONS

Incision and drainage (I&D) is the definitive treatment

for any subcutaneous abscess. Abscesses should be drained

if larger than 5 mm and accessible to percutaneous incision. Antibiotics alone are not adequate treatment of an

abscess. In fact, skin abscesses without surrounding cel ­

lulitis, once drained, do not r equire any further treatment

with antibiotics.

Abscesses can be diagnosed by physical examination

based on swelling, pain, redness, and fluctuance (Figure 1-1).

Some abscesses will spontaneously drain, leaving little diagnostic doubt. Bedside ultrasound may aid in diagnosis by

identifying a hypoechoic area of fluid just under the skin.

Needle aspiration may also be employed to prove the presence of pus.

Abscesses are often denoted by various names depending on their location and/or structure involved. The t reatment remains the same. Paronychia and eponychia form

around the nail (Figure 1-2). Felons occur with infection of

the volar pad of the finger and require a specific approach

for drainage. Bartholin gland abscesses occur in the paired

glands that provide moisture to the vestibule of the vaginal

mucosa. When the opening becomes occluded, either an

abscess or a cyst can develop. After I&D, a Word catheter is

placed to insure continued drainage of the gland. Removal

or marsupialization of the gland may be required to prevent recurrence.

1

• Abscesses should be probed with curved hemostats to

break up loculations and identify deeper tracks.

• Local anesthesia may be difficult and require additional

field block, parenteral analgesics, or sedation.

Hidradenitis suppurativa is a chronic relapsing inflammatory process affecting the apocrine glands in the axilla,

inguinal area, or both. Multiple abscesses can form and

eventually lead to draining fistulous tracts that require

surgical management. I&D of these abscesses is frequently

necessary and performed in the emergency department.

Incision and drainage may also be used to treat infected

pilonidal or sebaceous cysts. Further treatment by a

.A. Figure 1-1. A subcutaneous abscess in an intravenous

drug user.

CHAPTER 1

Figure 1-2. Paronychia.

surgeon will often include removing the capsule to prevent

recurrence.

Perirectal abscesses include superficial abscesses (ie,

perianal), which can be drained by emergency physicians,

and deeper abscesses (ie, ischiorectal, intersphincteric,

supralevator), which require operative surgical drainage.

Perianal abscesses present as tender, fluctuant masses palpated around the anal verge. Deeper abscesses often present with rectal pain, pain with defecation, rectal and

buttock erythema and tenderness, and systemic symptoms

( ie, fever, lethargy).

CONTRAINDICATIONS

Cellulitis without evidence of underlying abscess should

not be incised. Pulsatile masses that may be infected pseudoaneuryms should not be incised.

Extremely large or deep abscesses should be considered

for drainage under anesthesia. As a result of transient bacteremia, those patients at risk for endocarditis owing to an

artificial or abnormal heart valve should be given appropriate perioperative antibiotics.

Abscesses of the palms, soles, nasolabial fold, breasts,