Facing surgery for I & D of abscess and placement of seton... I need advice!

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BellaBoo
New Member


Date Joined Apr 2009
Total Posts : 3
   Posted 4/1/2009 10:18 PM (GMT -7)   
I'm a 26-year-old woman and have had gastrointestinal issues that come and go over the last 4 years. (gastric ulcers, chronic salmonella that lasted 5 months, inflammation in the illeum, anal fissures, hemmoroids).
 
I started having ulcers in Jan. 2005, for no apparent reason (I tested negative for elevated gastrin levels and h-pylori multiple times). My GI doctor continued doing endoscopies and ordering X-rays and CTs without determing a cause.
 
Then in Dec. 2005, I got Salmonella while vacationing in Mexico, along with several people I was with. We all had fevers, but my roomate had vomiting, while I mostly had diarrhea. I took some antibiotics and probiotics that the Mexican doctor left with us, and felt mostly better within a week. After my return home, I went to get a previously-scheduled CT, and of course, it showed inflammation. My GI doctor immediately did several colonoscopies. And before long, he had diagnosed me with Crohn's (which was a convenient way to explain both the ulcers and the inflammation), despite the fact that I told him and his nursing staff MULTIPLE times that I had recently had Salmonella.
 
Before beginning the Pentasa regimen he prescribed, I FINALLY convinced him to run a stool culture, which (of course) came up with an active Salmonella infection. Since the Salmonella explained my inflammation, and a genetic test came back negative, the Crohn's diagnosis was retracted.
 
Unfortunately, all the stress on my body from repeated tests and infection ended up causing some anal fissures and hemmoroids, which were a lot of pain and trouble, but which eventually healed and stayed that way for a year and a half.
 
BUT NOW, I have a rectal abscess, probably caused from a re-opened fissure. It has an opening inside my rectum through which it is draining, so from my understanding it is not considered a fistula, because it hasn't tunneled its way to the outside world. It created a hard, painful lump that I could feel from the outside. Three weeks ago, my colon-rectal surgeon recommended doing an I & D for the abscess, and then putting in a draining seton (thereby creating a fistula) to allow the abscess to continue to drain and prevent it from refilling with infection.
 
I've been on Cipro and Flagyl for the past three weeks, and that (along with drinking lots of water and manually pushing on the abscess to get it to drain) has caused the abscess to get MUCH smaller. In fact, I can hardly even tell it's there anymore. At my appointment yesterday, my CR surgeon said given how much it's improved, she is still STRONGLY recommending the seton, but would be comfortable just doing the I & D and sewing me back up.
 
I've scheduled the surgery, and now have a week and a half to decide what to do. I know that abscesses have a tendancy to refill with infection even after they've been drained, and I know that the seton would prevent this. I've also read a few places that once drained, abscesses end up becoming fistulas on their own, which makes a good argument for my doctor to just go ahead and "create" a fistula with the seton drain.
 
However, I'm very concerned about my quality of life and/or lifestyle changes by having a seton and fistula. Will I need to wear granny panties or boyshort underwear 24/7 to cover the seton/fistula? Will I have to wear a pad all the time? Will people be able to see the seton sticking out if I wear tight pants or a bathing suit? Will I even be able to wear a bathing suit or go swimming without having drainage? (I live on a lake, so this is a very important question)! Given my history of hemmoroids, won't a tube taking up space in my rectum just make BMs even more difficult to push out painlessly? And finally, as a single twenty-something, what about dating/sex?!
 
Right now I'm considering just doing the I & D and seeing what happens, especially considering the abscess had drained A LOT on it's own in the past three weeks. But if doing the I & D is just going to cause a fistula anyway, perhaps it is better to just go ahead and have my doctor "create" one with the seton...?
 
Further complicating the decision is the fact that my Crohn's diagnosis is still somewhat uncertain. If I do have Crohn's it is a fairly mild case, as I pretty much have normal bowel habits (when eating right and not battling a bacterial infection). The only indicators of Crohn's are the ulcers, anal fissures, and now this abscess.
 
I am so torn... I don't want more problems but I don't want to take too drastic of a step if it's uneccessary. Does anyone have any insights to share?

Trad
Regular Member


Date Joined Mar 2009
Total Posts : 24
   Posted 4/2/2009 2:57 AM (GMT -7)   
I had a seton in for about 7 month and didn't need to wear anything special just used a ladies pad during the day. You may need to bath 2-3 times a day but otherwise probably wouldn't even know it was there. Also my sphincta is basically destroyed from a similiar Abcess/fistula which go more and more aggresive after each surgery so eventually had to get ostomy so i never had to pass a stool while having the seton.

If you are going to operate get your doctor to do a biopsy and check for granulomas which i a sign of either TB or Crohns. This is however not a 100% test as my biopsy only showed signs of abnormal growth after being diverted. The Dr. Explained that while my body was fighting the infection caused by the fistula and ever passing stool, the crohns was not active. However after being diverted the tests came back positive.

In your case the chronic salmonella is complicating and already very difficult diagnosis so even if a biopsy is done the results may be neg due to that infection.

Dating/sex with the drain/seton will not be impossible, like i said above you probably wont even know its there. I have an ostomy and with understanding people I live a normal life.

PAssing a stool after your surgery is going to be painful, once it has healed the drain/seton should give you no problem. However imagine thrush from the anti-biotics just after sugery.

My fistula/abcess that I got in Mar 2006 burst inside be instead of out of th skin and this complicated it alot I think if it was drained property pro-actively it would have been better. I just had another sugery for the same fistula in Feb 09 ( The 9th in total). Make sure you have a good colo-rectal surgeon.

FallColors
Veteran Member


Date Joined May 2007
Total Posts : 1220
   Posted 4/2/2009 4:01 AM (GMT -7)   
Hello BellaBoo!

Welcome to the forum!
 
I know these are difficult areas when you are so new to all of this.  I strongly suggest you search old posts because there has been a lot of discusion of abscesses, fistulas, and setons.  Use the "Search Site" bar at the top middle of the page.
 
I&D is the way to take care of abscesses according to my colo-rectal surgeon.  Anyone can get abscesses and they are more common than we think.  My doctor said people don't know how common rectal abscessess are because its not exactly something discussed at dinner parties!  It is quite possible that you don't have Crohn's at all.  I agree with Trad that a biopsy of tissue around the abscess opening is often used to determine if it is Crohn's. 
 
I wonder about "making a fistula".  The body creates the fistula and they are difficult to deal with because they often do not disappear on their own.  The fistula is not a raw hole, but the body creates a tube that is lined with a tissue that allows it to stay an open tube.  I am wondering if they are just going to insert a regular drain that will be removed when you heal a little bit.  My surgeon says drains are a common way to treat deep abscesses for people who don't have Crohn's.  The drain is like a straw that is stitched in place and allows the deeper end of the abscess to heal.  Once the drain is removed, the hole made for the drain tube will heal up completely (unlike a real fistula).  I assume you will have wear pads to catch drainage.  The I&D in this case is a smaller incision that is stitched up around the drain.
 
In Crohn's, my surgeon says because we heal more slowly and more difficultly, the best treatment is to open up the abscess completely, and scrape it out, and let it heal on its own.  They don't sew up the wound after the I&D but leave it open to heal on its own.  While this is gross, it is better that getting bacteria trapped in the sewn-up wound and re-abscessing!
 
Whether it is a drain or seton, you certainly can live a great life.  You will learn how to keep it clean and how to wrap guaze around it to catch any drainage.  They will not be visible outside your panties. 
 
Here is a good article that discusse care and treatment of rectal abscesses and fistulae:
 
I suggest you read, read, read on this Forum and from reputable websites like the one I just gave you.  This will help you understand better the treatment options you doctors recommends and help you make informed decisions.
 
Let us know how it goes with you.  Take care!


Diagnosed with rectal Crohn's in early 2007.  Several peri-rectal abscesses and two fistulae with setons.  Allergic to Remicade and Humira.  Currently on 6MP, and vitamins D and B-12.

Post Edited (FallColors) : 4/2/2009 5:34:23 AM (GMT-6)


Jenn
Regular Member


Date Joined Oct 2004
Total Posts : 29
   Posted 4/2/2009 6:31 AM (GMT -7)   
All good and reasonable questions/fears. I had a seton placed in January and was positive it was going to be some huge thing (cause my CR surgeon didn't take any time to explain squat to me!) but it's not. I'll be blunt, mine goes into my sphincter, up inside my rectum, through my fistula and comes out the fistula opening, which is maybe 1/2 inch or less to the left of my sphincter. The seton itself is red, very small in diameter and stays right up against my skin (it looks like I swallowed a red rubber band). Nothing hanging down, so totally unnoticeable when your standing (it's well, hidden in the flaps of your butt cheeks, for lack of a better way of saying it).

I thought I was going to have to use feminine or incontinence pads, but quite frankly (for me at least) the drainage is slight enough, that by the time the ick could ooze down to a pad, I would feel so gross, I opted to not go with that method for catching the drainage. I went to my local pharmacy and purchased some 2x2 inch gauze squares (the brand I use is Invacare) and I place one firmly up against my sphincter whenever I leave the bathroom. They are so small, they fold in half and stay there held in by my butt cheeks, haven't lost one yet! This works really well for me, others may have a lot of discharge, so your mileage may very. I heartily recommend sitz baths at the beginning. Swimming, I guess you would just leave off whatever method your opt to use for the duration and reapply after your done. It's not like these things gush tons of stuff out. Or maybe that's just me?

As far as BM's, nope, don't really notice it at all, it's very small and not really in the way. The only time you might notice it is if you catch it on the TP and tweak it, then, it's a little painful, but not horrible and you just don't do that again!

My worst problems with my seton so far have been twisting/turning the stitch and getting stabbed by the somewhat rough edges, ouch, kind of painful. But for the most part, it's been pretty easy and comfortable to live with. As far as sex and dating, well, that's harder to say. I've been with my partner for 16 years, and well, she occasionally gets dragooned into looking down there to tell me how things are going (it is in a rather unviewable area) and she doesn't think it's too weird. The worst that has happened with it was once during sex, my little pad slipped out and was hanging out like a flag twixt my cheeks and we had to pause cause I'm like, what is going on?, well, the cat was behind me pitty patting the pad, cause hey, mom suddenly had a tail! And then he was removed from the bedroom and we continued on.

Once you get used to it, you really won't notice it most of the time. Good luck!

Post Edited (Jenn) : 4/2/2009 4:58:29 PM (GMT-6)


MissCris
Regular Member


Date Joined Jun 2006
Total Posts : 321
   Posted 4/2/2009 8:55 AM (GMT -7)   
First I just want to say that I'm sorry you are going through this and that you have to make this decision. This is probably the one place you will go for help that everyone can really empathize.

I hate to be the bad guy :( You may have an experience like Jenn which sounds pretty manageable. Unfortunately my experience has been a little different. I had a soft seton placed in January to allow my fistula to drain without abscessing while they decided what was to be done with me. Unlike Jenn's, my seton does hang out. It is basically a piece of surgical cord that loops through my rectum and the bartholin's gland and is knotted on the outside. It has 2 long strings that hang down. This may be because it was not intended to be an actual seton but just a way to keep it open and draining but after 2 months, it gets a little old.

If you ended up with something like that you could always trim the strings down I'm sure. The thought of wearing a bathing suit puts me into the fetal position so I haven't had any issues like that. However, I haven't been able to see it if I'm walking around the apartment in my underwear or anything. You don't have to wear granny panties but I would suggest staying away from thongs. (I hope you aren't wearing them anyway since you have a history of fissures :P)

Initially I had a lot of drainage from the surgery and it has been off and on since then. It's always blood, sometimes a little bit of stool. I would recommend wearing panty liners unless you discover you don't have that problem. Sitz baths are a good idea, I personally hate them because I find it painful to sit like that. I have been able to contort myself in the shower to allow the hot water to run over it, which I much prefer lol.

I'm not sure where your opening for the man-made fistula would be but I will tell you that for me, going to the bathroom for the first month was extremely painful. I tried as hard as possible to reduce the number of BMs I had a day. Now it is not as painful but I have to press on it after I go to the bathroom to drain any remaining stool out of the fistula. The biggest problem that I have had is passing gas through it, it was not as much of a problem initially but the seton has started to cut through a little and I have noticed that if I am gassy at all...there's no stopping it.

As far as your abscess healing with the antibiotics, that's awesome!! I hope that that can keep it away for you but unfortunately it didn't for me. I had to stop taking the Flagyl because it didn't help and I felt like it was giving me extra BMs which was making the inflammation worse. I stayed on the Cippro and that seemed to help off and on. My abscess seemed to be almost completely gone as long as it was draining and the antibiotics helped. The only problem was that every so often, one side or the other would close up and it would get swollen and painful again.

I would suggest talking to your doctor/surgeon about some of the concerns that you mentioned. They may be using different techniques than what we on the forum have experienced and everyone heals differently. Personally, if someone told me that they were going to make a fistula, I would be terrified. It seems like a really unfair decision for you to have to make. However, FallColors mentioned some stuff about the "created" fistula that makes it sound like it wouldn't be a terrible idea. Again, I would speak to your surgeon and find out if those things are accurate. Would the fistula they create be easier to heal than a natural fistula because of the lining? If not, I personally wouldn't do it because naturally occurring fistulas are SO hard to heal up.

Anyway, good luck with all of this and I hope you can get it all worked out soon.
"Be ashamed to die until you have won some victory for humanity" ~ Horace Mann


Ladybugs
Regular Member


Date Joined Jan 2006
Total Posts : 158
   Posted 4/2/2009 9:24 AM (GMT -7)   
Hi - I'm sorry you're having these problems.
 
I'm a 33 yo female.  I was diagnosed w/ Crohn's when I was 29.  I started having trouble with rectal abscesses right away.  The first few were treated with Flagyl and cleared up.  Then I got a horrible abscess that wouldn't clear up.  I was admitted to the hospital for three days.  The surgeon drained the abscess and placed a seton.  The pain from the abcess was gone immediatly, but the "plug" of skin and tissue that they had to take out when installing the seton remained quite painful for a good month. 
 
I've now had the seton for nearly two years.  I haven't had another abcess (knock on wood!).  The seton is a pain (literally) because if it twists wrong or pokes wrong, it really hurts, but for the most part I don't notice it's there.  Mine drains a lot.  Like some of the others have mentioned, I would feel gross wearing a pad because the drainage would be all over me, so I use a 3x3 gauze pad folded in half and stick it between my cheeks (glamorous, I know!) that absorbs the drainage.  I change it every time I go to the bathroom.  You totally won't be able to see the seton through tight pants or a bathing suit.
 
Best of luck to you.

crohn's pt mom
Regular Member


Date Joined Nov 2008
Total Posts : 86
   Posted 4/3/2009 8:03 AM (GMT -7)   
My daughter has 3 drains in now, apparently the abscess runs from almost her tailbone to her girlie parts; one drain is at the top near the tailbone, another in the middle and then the more uncomfortable one that is next to the vagina.  I've never seen her drains and I helped her to the bathroom and get dressed when she was in the hospital.  She does have to wear the boycut undies - so I buy pretty ones and at least for the first weeks (3 now) she has worn a feminine pad.  Her drainage after her last surgery required two pads at a time.  Now its slowing down - don't know about the future.  Sometimes the drains cause discomfort or pain but nothing like the pain of the abscess.

BellaBoo
New Member


Date Joined Apr 2009
Total Posts : 3
   Posted 4/5/2009 1:58 AM (GMT -7)   
Thanks everyone for all the advice! It SO helpful for me to know what I'm getting into! (And Jenn, that story about the gauze pad and the cat was HILARIOUS :-)

I guess all your responses also make me question my CR surgeon's advice a little bit. From what I've read elsewhere on this forum and other sites, it sounds like setons are usually placed AFTER a patient develops a fistula, whereas my doctor seems to want to place one in the spot where she ANTICIPATES I will develop one after my abscess is drained. From what she's told me, her thinking is that: a) Patients who have abscesses drained often develop fistulas afterwards, and b) People with Crohn's are more likely to have reccurant abscesses.

As for your insights, FallColors, my doctor definitely said she was putting in a seton. And she also stated that if she didn't put in the seton she would just "drain the abscess and sew me back up." Maybe I can mention to her your idea about leaving it open...? I think if she left it open on the outside, that would basically be the same as "creating" a fistula, because my abscess already has one opening on the inside of my rectum, so leaving the outside incision open would make a complete two-sided path... but I will definitely ask.

As some of you mentioned, part of my questions have been whether a "created" fistula right now would be better or worse than a naturally-occuring one (that may or may not appear later). LadyBugs, did you have a true fistula (a two-sided tunneling) when you had your seton put in? It sounded like maybe you were in my situation, and your doctor placed the seton to help permanently eliminate the abscess.

Right now I'm leaning towards just having her drain the abscess and see how it goes. I am really not having much pain, only the occaisonal throb, as the abscess itself has continued to drain from the one internal opening it has. It does cause a little bit of a dilemma with the hemorroids though -- when I use suppositories and creams for the hemorroids, they encourage the abscess's internal drainage hole heal, thereby trapping the infection. But I'll take hemorroids over abscesses any day.

I actually feel worse from the antibiotics than anything else -- I have raging thrush and a vaginal yeast infection, plus diarrhea so bad that my doctor thinks I might have C-Dif now... and possibly even an intestinal yeast infection (rare, she said, but I've been super yeast-prone all my life, and other family members of mine have gotten esophogeal yeast infections) so per my doctor's orders I'm taking Fluconazole daily and have stopped the Cipro. Now I'm still going to the bathroom more than my usual once-a-day, but not as much as I was last week.

Before starting this antibiotic regimen, I NEVER got diarrhea (except for those 5 months I had salmonella) ... my BMs typically come in three varieties: hard, harder, and darn-near-impacted. (not typical Crohn's, hence the constant raised eyebrows from GI docs and multitude of unanswered questions). And as far as the granuloma test, my GI already looked for it with each of my last colonoscopies. Neither showed any granulomas, and one was done with an active salmonella infection, while the other was done after the infection had cleared.

I have a CT enterography on Monday to check for inflammation and perhaps get a more conclusive Crohn's diagnosis. I'm hoping the results aren't misleading due to the C-Dif that I now may have from being over-antibioticked...

This is what always happens to me! I get chronic bacterial infections that cause inflammation, and then no one can tell whether it's really Crohn's, or just the body's normal response to infection! Very frustrating... Crohn's or not, I definitely have some sort of autoimmune malfunction going on...

I will keep you all posted! And thanks again for all your support! It is so wonderful to have discovered this forum :-)

FallColors
Veteran Member


Date Joined May 2007
Total Posts : 1220
   Posted 4/5/2009 5:30 AM (GMT -7)   
Hello BellaBoo,

I have serious doubts about your doctor. The idea of "creating a fistula" by using a seton is just crazy to me. You don't always develop a fistula and let me tell you that you don't want one if you don't need one! You may never be able to get rid of it!

The I&D procedure will cut into the abscess from your skin (not from inside your rectum). Once scraped out, the wound is left open to heal - it is not sewn closed. Here is a quote for a good website "You may not have stitches. Infected wounds such as abscesses are left open to drain. If they were stitched shut, they would just fill with pus again." http://www.emedicinehealth.com/anal_abscess/page8_em.htm

If your doctor is saying that a seton is necessary to keep another abscess from forming, I thinking that means her patients are reabscessing -- and probably because she is sewning the wound closed. If she treated it properly, the wound will heal and you might never get a fistula.

Another good quote -- "Does an abscess always become a fistula? No. A fistula develops in about 50 percent of all abscess cases, and there is really no way to predict if this will occur." http://www.fascrs.org/patients/conditions/anal_abscess_fistula/

Please please don't let her do anything to you before you see another doctor. You could print out and show her these websites, but she probably will still think her way is best. See another colo-rectal surgeon who really knows CD.
Diagnosed with rectal Crohn's in early 2007.  Several peri-rectal abscesses and two fistulae with setons.  Allergic to Remicade and Humira.  Currently on 6MP, and vitamins D and B-12.

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