Infection may spread and seek the path of least resistance (Fig. 1). It may extend downwards into the intersphincteric space resulting in a perianal abscess (A), upwards inside the longitudinal muscle layer within the gut wall causing an intermuscular abscess, or upwards outside the gut wall resulting in a supral-evator abscess (E). It may spread across the external sphincter (B) at any level resulting in an ischiorectal abscess which may also extend upwards or downwards (C). Furthermore, circumferential spread is possible at any level within the intersphincteric space, the ischiorectal space or the supralevator space. It may extend from one ischiorectal fossa to the contra lateral one via the intersphincteric space of Courtney or deep postanal space [20] resulting in a so-called horseshoe abscess.

The main symptoms of an abscess are discomfort, perianal pain and swelling. The symptoms develop

Ischiorectal Abscess
Fig. 1. Location of the abscess in the perineal spaces: A, perianal abscess (intersphincteric). B, perianal abscess (transsphincteric). C, ischiorectal abscess. D, submucosal or high intramuscular abscess. E, supralevator abscess (pelvirectal)

more or less rapidly within hours or days. The clinical presentation can include swelling, tenderness, induration at palpation, asymmetry of the buttocks, redness, superficial cellulitis, or even gangrenous skin. Inguinal lymph nodes may be enlarged. Systemic symptoms such as fever, chills, malaise, and tachycardia occur more frequently with high or deep abscesses than with more superficial ones. Only a careful rectal examination reveals the development of a high anorectal abscess.

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