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Research Article

The Pattern and Management of Gluteal Abscess Disease at


Al-Yarmouk Teaching Hospital
Haqqi I. Razzouki CABS ,Sattar J. Kadhim CABS, MRCS , Amer H.Salman CABS,DS

Abstract
Background: Despite the improvement in health care in general and
antiseptic techniques in particular, cases of gluteal abscess following intra-
muscular injections are still encountered. Although this condition is not
considered a serious illness, still it causes complications and exerts a pressure
Date Submitted:31-10-2012 on health resources.
Date Accepted: 1-07-2013
Objectives: To determine the factors responsible for the development of
gluteal abscesses and to suggest measures to avoid this problem and to study
the methods used in management.
Methods: This is a prospective analytic study in which all patients admitted
Address for Correspondence: to the surgical ward with gluteal abscess over a six months period were
Haqqi I. Razzouki included. Detailed demographic, clinical and investigative data were
Department of General recorded. Predisposing factors and co-morbid conditions were documented,
Surgery, Al-Yarmouk also, the persons who did the injection, the types of drugs used and other
Teaching Hospital factors related to the process of injection were studied. The contribution of
the human, technical and pharmacological elements were analysed. The
methods used in management, early post-operative complications and the
final outcome were recorded.
Results: Forty-two patients were included in the study; of those, 30 were
females (75%) and the mean age was 35 years. Eighteen were diabetic
(42.8%) and 16 (38.04%) were over-weight. Thirty-eight patients (90.47%)
had history of preceding intra-muscular injections. Most of the drugs used
were antibiotics, mainly Cefotaxime used in 14 patients (33.33%). There was
also 8 instances related to Diclofenac injection (19.04%) and 4 related to iron
preparation (9.5%). There were 8 instances of mixed injections using more
than one drug (19.04%). Twenty-eight episodes were related to under-
trained personnel (66.67%); 20 female nurses (47.62%) and 8 male nurses
(19%). Forty patients presented mainly as local pain(97%) and 36 patient as
visible swelling(90%). The main method of diagnosis was clinical. All patients
were treated surgically mostly using general anaesthesia (95%) and frank pus
obtained in 34 patients(80.95%). The most common organisms obtained on
culture were coagulase-positive staph.aureus and proteus.
Conclusions: Gluteal abscess disease is still common despite advances in
anti-septic techniques. Most of the cases are due to the lack of experience and
improper training of para-medical personnel. This condition is seen more
with certain types of drugs and in immune-compromised patients like
diabetics.

Keywords: Gluteal Abscess, Pattern, Management

INTRODUCTION It is usually related to intra-muscular injections although


other causes has been documented.Intra-muscular
Gluteal abscess is defined as collection of pus in the injections has been used as a means of parenteral drug
subcutaneous plane of the gluteal region. administration for over a century. These injections are
routinely performed by nurses and ancillary staff. The

Mustansiriya Medical Journal Volume 12 Issue 2 December 2013 | 34


Haqqi I. Razzouki et al.: Management of Gluteal Abscess Disease

incidence of developing a complication from these the period from Oct. the 1st 2011 to April the first 2012
injections range from 0.4 to 19.3% 1.Greenblatt et al were included in the study.
found that 46% of hospitalized medical patients
Relevant demographic data was recorded. The pattern of
received at least one intra-muscular injection during
clinical presentation was documented including: local
their stay[1] .Only 48 of 12134 patients(0.4%) were
pain, swelling, parasthesia, discharge, fever, chills and
reported in this study to have had one of the following
rigors, tachycardia, nausea and vomiting, and backache.
complications: abscess, induration, erythema, wheal
formation, persistent local pain, hematoma, bleeding, The predisposing factors were documented with special
and subcutaneous nodularity1.Pediatric nurses, on the emphasis on the history of intramuscular injections. The
other hand, report a much higher incidence. Twenty– patients were questioned thoroughly about the details of
three percent of those surveyed had seen a complication these injections including the type of drugs used, the
from an injection they had given[2]. Paralysis from person who performed the injection, site of injection,
infiltration of the sciatic nerve is an especially dreaded type of syringe, technique of injection and early post-
problem. Other serious complications include fatal gas injection complications.
gangrene, distal ischemia due to intra-arterial injection Other etiological factors like trauma were inquired
of epinephrine and quadriceps myofibrosis[3]. about. Relevant medical history like diabetic disease and
Other rare complications reported include: scar other immune-compromising illnesses were recorded.
formation, muscle fibrosis with contracture of joints, Besides, surgical history, especially operation for
and very rarely development of malignancy at the site of similar conditions, family history and relevant social
injection[1]. The primary factor contributing to most history were documented.
complications is improper placement of the injection. Detailed local clinical examination was done and the
The classic placement in the upper outer quadrant of the findings recorded on a special chart.
gluteal region has fallen out of favor because of hazard Systemic clinical examination and basic investigations
to the sciatic nerve and gluteal vessels if the injection is were done for all patients. For some patients additional
too medial to this quadrant[4]. investigations like ultrasonography and CT-scan were
The Swiss anatomist von Hochstetter studied the done.
problem and concluded that gluteal injections should be Details of the surgical treatment were documented
placed in a more lateral triangle bordered by the anterior including the type of anaesthesia, type of incision, the
superior iliac spine, the tubercle of the iliac crest, and findings in detail and the use of drains.
the upper border of the greater trochanter.
General anesthesia was mostly used. Incision and
His recommendations have been advocated and drainage of the abscess was the method used in the
implemented by nursing instructors[5] . A short needle surgical management. The type of antibiotics used, in
can also be a problem. Cockshott et al had nurses mark the pre- and post-operative period, and early post-
injection sites on patients before CT of the pelvis. In the operative complications were recorded. Pus drained
majority of adults, the thickness of gluteal fat was during operation was sent for culture and sensitivity.
greater than 3.5 cm[6]. Post-operatively, intra-venous antibiotics mainly
Since Cockshoot et al assumed that most needles were Ceftriaxone and Metronidazole were used until the
inserted about 3.0 cm intra-lipomatous instead of results of culture were obtained. Patients were followed
intramuscular injections were the rule rather than the for one month post-operatively and recurrence or
exception. Such injections are usually more painful, continuous discharge were observed.
since the pharmacological agents are more slowly
RESULT
absorbed. Treadwell suggested that most of the
problems stemming from the procedure are related to Forty – two cases were diagnosed with gluteal
local trauma of the injection itself or the irritating abscess during the period of the study. Thirty were
properties of the drug[7].Many of the complications are females (71.42%) and 12 were males (28.57%).Patients
also related to inadequate training in the proper injection were mainly in the third and sixth decades of life (and
technique [7] 10 patients each). Table-1 shows the demographic data
regarding the gender and the age.
PATIENTS AND METHODS
This is a prospective analytic study. All patients
diagnosed with gluteal abscess and treated at the
surgical wards in Al-Yarmouk Teaching hospital during
Mustansiriya Medical Journal Volume 12 Issue 2 December 2013 | 35
Haqqi I. Razzouki et al.: Management of Gluteal Abscess Disease

Table 1: The demographic data The type of drugs used were mainly antibiotics, NSAID
and iron preparations. Fourteen patients (35%) received
Gender
Male Female Cefotaxime, 4(9.52%) received Ceftriaxone and one
NO % NO % each received Ampiclox and Ampicillin. Eight patients
12 25 30 75 received Diclofenac, 4 received iron preparation,
Age
another 2 received steroids and one each received
NO % NO %
0-9 Year 0 0 0 0 Aspegic and a hormonal preparation. In some patients 2
10 – 19 Year 1 2.38 2 11.9 drugs were mixed in the same syringe, mostly
20 – 29 Year 3 7.14 7 16.66 antibiotics and analgesics. In all cases the site of
30 - 39 Year 2 4.76 6 14.28 injection was in the upper outer quadrant of the gluteal
40 – 49 Year 1 2.38 4 9.52
50 – 59 Year 3 7.14 7 16.66
region. Disposable syringes were used in all cases. Table
˃ 60 Year 2 4.76 4 9.52 -4 showed the type of injected drug.

The mean age was 35±1.5.Eighteen patients were Table 4: Type of injected drug
diabetic (42.8%), 16 with type II and 2 with type I. Eight Type of Drug NO %
patients (19.04%) had history of cardio-vascular or
Cefotaxime Na 14 33.3
cerebrovascular disease and 2 (4.7%) had history of Ceftriaxone 4 9.52
deep venous thrombosis. Eight patients were chronic Ampiclox 1 2.38
smokers (19.04%), 16(38.09%) were over-weight and 2 Ampicillin 1 2.38
were morbidly obese (4.7%). Ten patients (23.8%) were Diclofenac 8 19
using steroid preparations, 12(28.57%) were on NSAID, Iron 4 9.52
8 (19.04%) were on aspirin and 4 (10%) were using Steroids 2 4.76
contraceptive pills. Twelve patients (28.57%) had Others 4 9.52
proven anemia, two had leukemia (4.76%) and one had
history of breast cancer (2.38%). The last three patients Injections were done as an outpatient procedure in 19
had received chemotherapy (7.14%) and one had patients (95%) and only two cases were inpatient.
received radiotherapy (2.38%). Table -2 showed the co- Twenty injections were done by a female nurse (49%),
morbid conditions. 8(19%) by a male dresser, 4 by a physician, 4 by a
relative and 2 by the patient himself. Table -5 showed
Table 2: Co-morbid conditions the personnel who is responsible for the injection.
Disease / Condition No % Table 5: Personnel responsible for the injection
Diabetes Mellitus 18 42.8
Cardio –Vascular disease 4 9.5 PERSONNEL NO %

Cerebro- Vascular disease 4 9.5 Male Nurse 8 19

D.V.T History 2 4.76 Female Nurse 20 49

Over –Weight 16 38 Physician 4 9.5

Morbid Obesity 2 4.76 Relative 4 9.5

Chronic Smoker 8 19 Patient 2 4.25

Chronic Steroid 10 23.8


The patient noticed immediate pain or parasthesia in 14
Anemia 12 28.5
instances (33.33%).Three cases of the post-injection
Malignancy 3 7.1
abscess (14%) were recurrent.
Thirty-eight patients (95%) had history of preceding There was history of recurrent or previous perianal
intra-muscular injection. Two patients had history of disease in 6 patients (14.28%).Three of those had fistula
local trauma, one blunt and the other penetrating. The in ano and three had hemorrhoidectomy.Two female
time since the injection episode ranged from 2 days to patients had history of recent gynecological disease.
60 days with a mean duration of 15±3 days. Table -3
showed the etiological factors of gluteal abscess. Clinically, most of the patients presented with pain and
swelling in the gluteal region.
Table 3: Predisposing factors
Forty patients had pain(95.24%) , moderate to severe ,
Cause NO % and 36 patients had visible swelling (85.71%).
Intra-Muscular Injection 38 95
Penetration Trauma 1 2.5 In 18 patient (42.85%) , the mass was fluctuant and in
Blunt Trauma 1 2.5
the other eighteen , the swelling was firm or hard by
Cause Unknown 2 5
palpation. In 6 patients (14.28%), the abscess had
already ruptured by time of presentation. Most of the
Mustansiriya Medical Journal Volume 12 Issue 2 December 2013 | 36
Haqqi I. Razzouki et al.: Management of Gluteal Abscess Disease

patients had systemic symptoms and signs. Thirty-two anemia and three patients had malignant disease which
patients had fever (76.19%), 18 (44%) had chills or was treated by chemotherapy. Clearly the use of an
rigors, 16 (38%) had tachycardia, 14 (34%) had nausea intra-muscular injection was the main cause (95%) and
or vomiting, 18 (44%) had gait disturbance and 10 only 4 cases were due to trauma. The duration since
(24%) had backache. The duration of the local injection ranged from 2 to 60 days. This may be due to
symptoms ranged from 2 days to 2 months. the contaminating bacterial dose, the presence of a
preceding hematoma, any accompanying immuno-
Basic biochemical investigations were done to all
compromised state and the use of antibiotics. Dudley et
patients. It revealed hyperglycemia in 16 patients (40%),
al believe that injection abscesses tend to develop slowly
leucocytosis and raised ESR in 18(44%) and anemia in
because they start more as an area of necrosis than as a
16(40%).Ultrasonography was done for 14 patients to
virulent infection[8].Gradually an indurated mass
confirm the diagnosis and was positive in all cases.
develops and eventually over a period of a week or two
Eight patients (20%) had received antibiotics without an abscess forms[8].
benefit. Surgery was done to all patients, 38(95%) under
McIvor et al believe that the immunosuppressant effects
general anesthesia and 4 under local anesthesia because
of some drugs like steroids may delay the local
of cardiovascular disease.Cruciate incision was done in
inflammatory response[4].
30 cases (75%) and transverse or elliptical incision in 12
cases. Frank pus was obtained in 34 patients (85%). In 4 The main drugs responsible were antibiotics, analgesics
patients (7.5%) there was a hematoma with secondary and iron. This is to be expected as these are the most
infection and in another four there was fat necrosis. commonly used intra-muscular preparations. However,
Gauze drain was left in the wound in 18 cases (44%), there may be some relation to the nature of these drugs.
corrugated drain left in 8 cases (20%) and simple
For example, iron should be injected deeply in the
surgical dressing in 16 cases (36%).In two patients a
muscle and by an experienced person, otherwise there is
foreign body (shell) was found and removed.
a high possibility of complications. Cephalosporins and
All patients received intra-venous antibiotics penicillin derivatives need proper dissolution by
postoperatively mainly Ceftriaxone and Metronidazole distilled water and if this is not properly done, they will
until the results of culture were obtained. The patients remain in crystalloid state and cause complications.
remained in hospital from 12 hours to 17 days with a AIso, these injections are painful and this may cause the
mean stay of 1+_50 day. All the patients were seen 10 patient to move during injection or tighten his
days after discharge from hospital. Six patients (13%) muscles[4]. This had been noticed also with analgesics
had recurrence and needed re-operation, 8 had serous like Diclofenac and Aspegic. Other drugs mentioned in
discharge which stopped after conservative treatment the literature include Chloroquine, Epinephrine and
and 28 patients had uneventful recovery. In all patients B.C.G vaccine[3]. The classical site of injection was
pus was sent for culture and sensitivity. The organism used in all patients ,so we do not think that this was a
most commonly cultured was coagulase- positive significant factor in the aetiology. The upper outer
staphylococcus found in 38 patients (90.47%) and quadrant is still considered acceptable despite the
proteus species in 4 patients (9.53%) suggestion by Hochstetter[5].

DISCUSSION It was not possible to observe the actual process of


injection, however the personal observations of the
Despite the wide use of sterilized disposable needles and authors indicate a wide use of improper techniques of
syringes and the use of antiseptic solutions, post- injection. Although diposable sterile syringes were used
injection gluteal abscesses continue to occur. Forty-two in all patients, however this was not enough to ensure a
patients were diagnosed and treated for gluteal abscess perfect anti-septic procedure.
during the period of the study. Seventy five percent of
these were females. This may be explained by the larger This is related to the experience and training of medical
adipose mass in the gluteal areas in females.The mean personnel .Most of the injections were done by nurses
age of those affected was 35± 1.5 years. There was a (49%) and dressers (19%) as an outpatient procedure
clear correlation with immuno-compromised states like .The fact that 68% of the patients noticed pain or
diabetes mellitus with an incidence of 45% mainly type parasthesia immediately or very early after injection
II. indicate the possibility that improper techniques were
the main causes of the abscess. McIvor et al believe that
Also,40% of the patients were over-weight or morbidly these abscesses develop due to pathogens carried from
obese. Twenty percent were chronic smokers and 25% the skin by the needle or seeded hematogenously into an
were chronic steroid users. Thirty percent had proven area injured or made ischemic by the injectate[4]. They
Mustansiriya Medical Journal Volume 12 Issue 2 December 2013 | 37
Haqqi I. Razzouki et al.: Management of Gluteal Abscess Disease

also believe that the primary factor contributing to most as gluteal abscess complicating dilatation and curettage
complications is improper placement of the injection[4]. for incomplete abortion[13].
In western countries , these abscesses are particularly Methicillin-resistant community-acquired Staph aureus
prone to occur in drug addicts who self-administer their had been reported by Dominguez to be responsible for a
drugs[8]. In drug addicts infective thrombophlebitis may cases of gluteal abscess[14] and Bey an et al reported a
accompany the abscess[8]. case caused by Brucella species[15].
In our study, there were two examples of self- Streptococcus intermedius is related to the milleri group
administration. Diabetics also self-administer their and is found as a mouth commensal.It was diagnosed as
insulin and the lesion may develop in the buttock or a cause of gluteal abscess[16].
lateral to the iliac crest[8]. Occasionally –but, because
The organisms obtained after culture in this study were
they are usually well trained, uncommonly – a diabetic
Staphylococci (90.47%) and Proteus species (9.53%).
will sustain an abscess in the thigh[8]. There was history
of previous or current perianal disease in 29% and this The above mentioned organisms were not detected. This
may facilitate the abscess by making the surrounding may be explained by the fact that the abscess in this
area contaminated and unhealthy. Presence of study is mainly related to improper method of injection
gynecological problems like pelvic inflammatory or improper sterilization and not related to a focus of a
disease may also play the same role [4]. disease process in another part of the body.

Clinically, the importance of injection abscesses lies in In many instances, gluteal abscess may be the first
their elusiveness and low grade fever may puzzle a presentation of another important disease process. In the
clinician for many days until he carefully examines case reported by Bardhan et al[17], gluteal abscess was
injection sites[8]. the first manifestation of diverticular disease and the
underlying cause was Crohn's disease as reported by
This is especially true in western countries because the
Hussein et al[18] in which the pus extended through the
condition is becoming rarer than before.
fascial planes of the pelvis and through the greater
The organisms responsible for local necrosis leading for sciatic foramen into the gluteal area. Perforation of
example to gluteal abscess are mainly staphylococci but advanced cecal adenocarcinoma resulted in gluteal
anaerobic strains will do the same[8]. abscess formation as reported by Mohandas[19].
These organisms are associated with rapid rise in tissue The diagnosis in gluteal abscess is mainly clinical.
tension often in fascial compartments which contain fat Detailed history and a careful clinical examination are
like the buttock[8]. essential. Checking blood sugar and complete blood
count should be done to all patients as there is a high
The result is severe local and sometimes general
possibility of hyperglycemia and anemia. In some cases,
symptoms and early necrosis with slough formation.
ultrasonography and CT scan are needed to confirm the
Dudley et al believe that the tempo of surgical
diagnosis or to exclude accompanying diseases. [9]
management must take account of this and, in particular,
the temptation must be resisted to prolong antimicrobial The principal management of gluteal abscess is surgical.
treatment when what is needed is decompression[8]. The General anesthesia is preferred and in many situations
focus of infection may be in another organ and proper muscular relaxation is essential[8].
transferred hematogenously.. Although staphylococcal
In our study, general anesthesia was used in 95% of
organisms are the main cause in this study and other
cases. Aseptic precautions must be as perfect as in a
studies, other organisms had been mentioned in the
clean case.Cruciate incision was made in most of the
literature. Puthezhath et al reported a case caused by
cases but transverse incision can be used also.
Mycobacterium tuberculosis[9]. The primary site was in
the spine (Pott's disease). The wound is deepened and all loculi should be broken
down so as to insure that there is one cavity.
Another source of T.B. is the abdomen as reported by
Karunakaran[10]. It is generally advised that the lining membrane of
granulation tissue should be abraded. After this the
Aligeti et al reported another case caused by Salmonella
choice lies between complete deroofing, so that drainage
typhimurium[11] while Sengupta reported another case
material is needed, and use of a drainage tube.
attributed to Entamoeba histolytica[12].
What appears to be a large cavity and serious cosmetic
Pyogenic infection with Streptococcus agalactiae is a
blemish usually quickly contracts[8].
potentially life-threatening disease which may present

Mustansiriya Medical Journal Volume 12 Issue 2 December 2013 | 38


Haqqi I. Razzouki et al.: Management of Gluteal Abscess Disease

Previously, filling the cavity with gauze was advised but 4. McIvor A, Palluzi M, Meguid MM .Intramuscular
nowadays this is not acceptable as will interfere with injection abscess-Past lessons learned. N Engl J Med
1991; 324:1897-98
proper drainage. Tube drainage is generally advised 5. Kozier B,Erb G. Techniques in clinical nursing.2nd Ed.
where there is a deep collection. Counter incision may Addison-Wesley1987:727-30
be necessary to secure dependent drainage, better still; 6. Cockshoot WP , Thompson GT , Seely ET , Howlett LJ.
the use of negative pressure vacuum drainage will give Intramuscular or intralipomatous injection? N Engl J
Med 1982; 307:356-8
better results. Some surgeons recommend primary
7. Treadwell T. Intramuscular injection site injury
suture, In a study by Khanna et, hundred cases of gluteal masquerading as pressure ulcers. Wounds 2003;
injection abscesses were managed by primary closure 15:302-12
technique under antibiotic cover with a tube drain left 8. Dudley HAF Ed. Hamilton-Bailey" Emergency Surgery
11th Ed. 1986; 11:107-13
in[20].
9. Puthezhath K , Zacharia B, Mathew PT. Gluteal
They claimed a complete healing time of 7-10 days and abscess:Diagnostic challenges and management. J
Infect Dev Ctries 2010; 4(5):345-48
reported no recurrence of the abscess and a neat linear
10. Karunakaran K . T.B. Abdomen presenting as gluteal
scar. Dudley suggested that this method may be useful abscess. Ind J of Surg 2008; 70:325-6
in very early cases[4]. In this study, the patients were 11. Aligeti VR, Brewer SC, Khouzam RN, et al. Primary
followed for a minimum of 10 days. Twenty-eight gluteal abscess due to Salmonella typhimurium. Am J
Med Sci 2007; 333:128-30
patients (68%) had complete recovery, 8 (19%) had
12. Senguptn SP, Biswas S, Pal NC. Amoebic gluteal
persistent discharge which healed spontaneously, and 6 abscess. Ind J Med Assoc 1977; 68:165-7
(13%) had recurrence for which re-operation in the form 13. Yansoun CP, Ponette V, Rouleu D. Bactrial sacroillitis
of drainage was needed.The type of drain used didn’t and gluteal abscess after dilatation and curettage for
affect the clinical outcome. incomplete abortion. Obstet Gynecol 2009; 114:440-
3
Conclusions 14. Dominguez JT. Community-acquired Methicillin
resistant staph aureus . J Am Board Fam Med 2004;
Gluteal abscess disease is still common despite 17(3):23
advances in anti-septic techniques. Most of the cases are 15. Beyah E , Pamukoglu M , Thra C, et al. Gluteal abscess
caused by Brucella species. Intern Med 2008;
due to the lack of experience and improper training of 47(3):171-2
Para-medical personnel. Gluteal abscess is seen more 16. Calza L , Manfreds R , Briganti E , Attard L , Ctriato F.
with certain types of drugs (like Cephalosporins and Iliac osteomeylitis and gluteal abscess caused by
Diclofenac) and in immune-compromised patients like Strepto intermedius. J Med Microbiol 2001; 50:480-
482
diabetics
17. Bardhan SK , Moragn E , Daniels IR , et al . A
diverticular pain in the bottom. Ann R Coll Surg Engl
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