Case Studies

Complex Perirectal Abscess Extending to the Preperitoneum and Space of Retzius

Caleb J. Mentzer, DO; James R. Yon, MD; Ray King, MD; and Jeremy A. Warren, MD

From the Department of Surgery, Minimally Invasive and Digestive Surgery Section, Augusta Univer- sity, Augusta, Ga (C.J.M., J.R.Y., R.K., J.A.W.)

Abstract Space of Retzius infections are rare and can be insidious until presenting as a large abscess cavity spreading to other extraperitoneal compartments. Knowledge of anatomy and of possible manage- ment pitfalls is key to successful treatment. We describe a case of space of Retzius abscess due to ascending infection from a perirectal abscess that was managed successfully and offer a review of the anatomy, pathophysiology, and management of this infection pattern. The case reported required multiple drainage procedures of the perirectal abscess and extraperitoneal spaces and treatment with antibiotics. After appropriate drainage, the patient progressed well to eventual discharge. This case highlights the complex anatomic compartments and potential spaces that exist which allowed a common, typically benign perirectal abscess to extend and cause severe systemic illness.

nfections presenting in the space of Retzius are the patient was transferred to our academic tertiary historically attributed to bladder infections, ura- referral center for further workup, approximately Ichal infections, osteomyelitis of the pubic sym- 36 hours after initial presentation. The patient physis, or granulomatous disease. Increasingly, sur- appeared uncomfortable with tachypnea and fever, geons are entering this space for procedures such as but was otherwise hemodynamically stable. His prostatectomies, orthopaedic manipulation of the pelvis, and laparoscopic inguinal hernia repairs. As with other extraperitoneal infections, patients Figure 1 typically present with vague and nonspecific com- Axial CT scan demonstrating air and fluid collection deep to anterior plaints. These patients often lack physical exam abdominal wall fascia. Area of interest outlined, displaying typical “molar findings, creating a diagnostic dilemma and poten- tooth” shape. tially delaying definitive treatment. Additionally, the complex extraperitoneal anatomic planes allow extension of disease from distant sites. We present a previously unreported space of Retzius infection arising from a perirectal abscess, along with ana- tomic review and summary of the literature. Case Description A 49-year-old man with no past medical history presented to an outside hospital complaining of perirectal and abdominal pain. The patient’s white count was 19 000 with a bandemia of 58%. A com- puter tomography (CT) scan revealed proctitis and a perirectal fluid collection. He was placed on broad-spectrum antibiotics, and the perirectal abscess was incised and drained, and a Penrose drain was placed. Secondary to worsening sepsis,

GHS Proc. May 2016; 1 (1): 49-51 49 exam was nonspecific with vague, diffuse, abdom- areas in the patient’s flanks allowed for adequate inal tenderness. He had normal bowel sounds, nor- drainage and wound care using negative pres- mal urinalysis, and no masses palpated on rectal sure wound therapy (NPWT). Wound cultures exam. Bowel function was reportedly normal. The revealed Escheridia coli, Bacteroides thetaiotami- Penrose drain placed by the referring hospital was cron, and Clostridium species. With serial wash- intact, and the incision and drainage appeared outs of this space, NPWT, and broad-spectrum open. After review of the patient’s original CT scan, antibiotic therapy, the patient went on to recover the decision was made to re-examine the patient completely over the next several months with no in the operating room with a proctoscope to eval- long-term complications. uate for any undrained collections, with the con- Discussion cern being there was an This rare extension of distant infection to the space Figure 2 area of multi-loculated of Retzius highlights the complex anatomic planes Sagittal CT scan showing extent of abscess abscess that was not fully that make up the retroperitoneal and extraper- from perirectal area to umbilicus. Area of drained. The abscess cavity itoneal compartments. Anders Retzius initially interest outlined. appeared to be adequately defined the prevesical space in 1856 at a report drained and no other presented to the Academy of Stockholm with sub- pathology was noted. sequent description of the first described infection 1 In the setting of continued in the area by Wenzel Gruber in 1862. Familiarity sepsis with an unidentified with this anatomy and the potential interconnect- source, a repeat CT scan ing spaces is critical for early recognition and treat- was performed (Figs. 1 and ment of such complex infections as presented here. 2). This revealed bilateral The anterior extraperitoneal space is created by 1 pneumonia and an extra- central and 2 paired folds of peritoneum extending peritoneal fluid collection from the umbilicus known as the median, medial, that extended from retro- and lateral umbilical ligaments. The lateral umbil- peritoneum anteriorly to ical ligaments are formed by the inferior epigas- 2 the space of Retzius, and tric vessels. The medial umbilical ligaments are superiorly to the umbilicus formed by the remnants of the obliterated umbili- without intraperitoneal cal arteries. The centrally located median umbilical involvement. Air within ligament is a peritoneum-covered ridge formed by the fluid collection, as well the obliterated urachus, connecting the umbilicus 2 as the patient’s clinical to the anterior dome of the bladder. Surround- condition, was indicative ing the median umbilical ligament (urachus) and of an undrained abscess. extending laterally to the medial umbilical liga- Figure 3 Figure 3 is a diagram ments is the umbilicovesical fascia. It is the combi- Diagram of abscess. A = Abscess, showing the extent of the nation of these folds and ligaments that forms the B = Bladder, C = Rectum. abscess and can be com- pathognomonic “molar tooth” outline of abscesses pared with Figure 2. The seen on CT. Inferiorly, the umbilicovesical fascia is patient was taken to the contiguous with the visceral fascia of the bladder. operating room where a Anteriorly, the umbilicovesical fascia is the umbili- lower midline incision was cal-prevesical fascia, and it extends from the umbi- used to gain access into the licus to the inferolateral surface of the bladder. The preperitoneal compart- space between the umbilicovesical fascia and the ment. A large abscess was umbilical-prevesical fascia at the level of the pubis evacuated that extended is known as the retropubic space of Retzius.3 This from the pelvic prevesic- space normally contains fat, loose fibrous tissue, ular space into the retro- and a perivesical venous plexus.2 Laterally, this peritoneum abutting the extends to the space of Bogros, which lies below spine, creating a free-float- the inguinal ligament and contains the iliofemoral ing peritoneum. The peri- vessels medially and the iliopsoas muscle more lat- toneum remained intact erally. Continuing posterolaterally, this is directly and no intraperitoneal contiguous with the infrarenal retroperitoneal structures were involved. compartments, and caudally extends to the supra- Separate incisions placed levator extraperitoneal space, potentially allowing in laterally dependent direct spread of infection between these spaces.3 In

50 GHS Proc. May 2016; 1 (1): 49-51 COMPLEX SPACE OF RETZIUS ABSCESS our patient’s case, the original perirectal abscess who remained febrile had a reported 71% mortal- Correspondence most likely extended cephalad through the suprale- ity rate.8 Overall, mortality rate of extraperitoneal Address to: vator space, continued into the iliac space, and then abscesses ranges from 22% to 46%.8 As our case James Yon, MD progressed in a lateral-to-medial direction into the corroborates, most extraperitoneal infections are Cook County prevesical space. Chen et al4 and Auh et al5 have due to Escheridia coli and Bacteroides species.8 Department of Trauma demonstrated that there is a direct communication and Burn from pararectal space to the vesicle extraperitoneal Management of complex extraperitoneal abscesses 1900 W Polk St space without a separating fascial layer due to the has been extensively discussed in the literature, Suite 1300 umbilicovesical fascia ending at the reflection of with percutaneous approaches being the favored Chicago, IL 60612 9-12 the vesical peritoneum. From the prevesical space, method as opposed to open surgical approaches. (jyon@ the infection was able to spread through the entire With increasing surgical manipulation of these cookcountyhhs.org) space of Retzius anteriorly, as well as into other pel- planes, the general surgeon must be familiar with vic compartments, and the retroperitoneum poste- their potential interconnections when consider- riorly, through direct spread. ing both source and intervention. Transperitoneal drainage should be avoided, as this leads to high Space of Retzius infection, as with other extra- rates of recurrence and increases mortality.8 peritoneal infections, is insidious and difficult to diagnose secondary to the absence of physical Conclusion signs. Patients can have vague and nonspecific Though a rare presentation, this case highlights complaints, with urinary frequency and urgency the complex anatomic compartments and poten- being the most specific to infections of the pre- tial spaces that exist in the extraperitoneum that vesical space.6 Bowel function is usually reported allowed a common, typically benign perirectal as normal, as reported in our case. While CT can abscess to extend to the supralevator space, and reveal and delineate many abscesses, infections in eventually to the space of Retzius. In the absence of the space of Retzius are often harder to identify rapid clinical improvement after initial drainage, due to the difficulty of ascertaining whether a fluid the clinician must have a high index of suspicion for collection is intra- or extraperitoneal.7 Because more complex disease and seek additional workup of the occult nature and indolent presentation of and treatment. Computed tomography scanning is extraperitoneal abscesses, there is often a delay in probably the best tool for evaluation, as the clinical diagnosis, and a high index of suspicion is needed. presentation of extraperitoneal abscesses is more On average, this delay has been reported as 12.7 insidious and can have little to no physical exam days for all extraperitoneal abscesses.8 In that signs with non-specific laboratory studies. Early study, postdrainage fever was a major prognostic consideration and identification of extraperitoneal indicator. Patients who defervesced postopera- abscesses is crucial for timely intervention in a tively in less than 3 days had an 89% survival rate patient’s care, as delays in diagnosis and treatment compared to those who remained febrile.6 Patients carry significantly higher morbidity and mortality. References 1. Rising EH. Prevesical abscess. Ann Surg. 1908:48: 7. Kobayashi S. Hematoma in the space of Retzius. J 224-36. Trauma. 2006;61:1556. 2. Marilas P, Skandalakis JE. Surgical anatomy of the 8. Crepps JT, Welch JP, Orlando R. Management and retroperitoneal spaces part II: the architecture of the outcome of retroperitoneal abscesses. Ann Surg. retroperitoneal space. Am Surg. 2010;76:33-42. 1987;205:276-81. 3. Korobkin M, Silverman PM, Quint LE, Francis IR. CT 9. Benoist S, Panis Y, Pannegeon V, Soyer P, Watrin T, of the extraperitoneal space: normal anatomy and fluid Boudiaf M, Valleur P. Can failure of percutaneous collections. Am J Roentgenol. 1992;159:933-41. drainage of postoperative abdominal abscesses be pre- dicted? Am J Surg. 2002;184:148-53. 4. Auh YH, Rubenstein WA, Schneider M, Reckler JM, 10. Brolin RE, Nosher JL, Leiman S, Lee WS, Greco RS. Whalen JP, Kazam E. Extraperitoneal paravesical Percutaneous catheter versus open surgical drainage spaces: CT delineation with US correlation. Radiology. in the treatment of abdominal abscesses. Am Surg. 1986;159:319-28. 1984;50:102-8. 5. Chen N, Min PQ, Liu ZY, Wu B, Yang KQ, Lu CY. 11. Cantasdemir M, Kara B, Cebi D, Selcuk ND, Numan Radiologic and anatomic study of the extraperitoneal F. Computed tomography-guided percutaneous cath- space associated with the rectum. Am J Roentgenol. eter drainage of primary and secondary iliopsoas 2010;194:642-52. abscesses. Clin Radiol. 2003;58:811-5. 6. Bellina PV, Lang EK, Hanemann M. Anterior abdom- 12. Gerzof SG, Johnson WC, Robbins AH, Nabseth DC. inal wall and space of Retzius abscess. J La State Med Expanded criteria for percutaneous abscess drainage. Soc. 1980;132:160-2. Arch Surg. 1985;120:227-32.

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