Cyst & Abscess Removal | Physicians Immediate Care

Cysts and abscesses are fluid-filled lumps that can form anywhere on the body. To the untrained eye, they can be hard to tell apart. Both cysts and abscesses can be uncomfortable, and may require medical treatment.

What is a cyst?

Cysts are sacs or cavities filled with fluid or pus. They can appear on your skin or anywhere inside your body. Some common types are the baker’s cyst (behind the knee), sebaceous cyst (under the skin), and ganglion cyst (along the tendons or joints of your wrists, hands, or feet).

The cells that make up a cyst’s sac are different from those around them, but they usually aren’t cancerous. Cysts grow slowly and are not typically painful. A cyst is not considered a medical problem unless it bothers you or becomes sore or infected.

What is an abscess?

An abscess is a tender, infected area filled with pus. Abscesses form when your immune system fights an infection in one of your bodily tissues.

Like cysts, abscesses can occur on your skin or inside your body. However, because abscesses involve infection, they are warm, painful, irritated, and often red and swollen. The surrounding area is usually colored from pink to deep red, and the infection can also cause symptoms in other parts of the body. An abscess can form on its own or can occur when a cyst becomes infected.

How to treat a cyst or abscess at home

One of the best things you can do to treat a cyst or abscess at home is to hold a warm, moist cloth on the area for 20 minutes at a time, a few times daily. This may soothe the area, stimulate infection-fighting antibodies and white blood cells, and help the area heal.

It’s not advisable to try draining a cyst or abscess yourself. Cyst popping at home can cause infection. Instead, keep the area clean, and make an appointment with a doctor if the area is painful or starts to drain.

How can a physician treat my cyst or abscess?

If you have a cyst or abscess that is bothering you, visit a medical provider to have it examined. At Physicians Immediate Care, most cysts and abscesses are drained and removed using one of the following two procedures:

Fine needle aspiration

In a fine needle aspiration procedure, a thin needle is inserted into the cyst, after the area has been numbed. Your medical provider will drain the cyst’s fluids through the needle. Patients typically experience no discomfort to minimal discomfort during the procedure.

Incision and drainage

With an incision and drainage procedure, your medical provider will start by numbing the area with a local anesthetic. He or she will make a small incision into the abscess using a scalpel or needle. The pus will then be drained from the abscess, and some of the discharge may be collected for testing. Once the abscess has been drained, the medical provider will clean the wound and rinse it with a saline solution.

After an aspiration or incision and drainage procedure, a few additional steps are taken. First, depending on the size and depth of the cyst or abscess, the physician will bandage the wound with sterile gauze or will insert a drain to allow the abscess to continue draining as it heals. Antibiotics may be given to help prevent or fight infection. The discharge collected may be tested for bacterial cultures or malignant cancers.

You may be asked to return to the clinic one or more times for additional treatments to complete the abscess or cyst removal process, especially if the area is large.

Where can I get a cyst or abscess removed?

Your general practitioner or dermatologist can diagnose and treat your cyst or abscess. Although needle aspiration and incision, and drainage are generally quick procedures, you may experience a significant wait time if your health professional is booked in advance. If you wish to see a medical provider immediately to evaluate a cyst, you can walk-in or reserve a time at a Physicians Immediate Care clinic. Please note that it is up to our provider’s discretion to remove a cyst. Depending on the type of cyst and location, a referral to a specialist may be advised.

With more than 40 clinics open extended hours, 7 days a week across Indiana and Illinois, you can have your health concerns taken care of right away. Our dedicated physicians and health care practitioners can drain and remove your cyst or abscess before your symptoms get any worse. Visit us to get fast, quality care for all your health needs today.

Incision and Drainage – StatPearls

Alyssa Pastorino; Melissa M. Tavarez.

Author Information and Affiliations

Last Update: July 25, 2022.

Continuing Education Activity

Incision and drainage (I and D) is a widely used procedure in various care settings including emergency departments and outpatient clinics. It is the primary treatment for skin and soft tissue abscesses, with or without adjunctive antibiotic therapy. This activity reviews the incision and drainage procedure, risks and benefits. The role of an interprofessional team will be discussed.

Objectives:

• Identify the anatomical considerations of incision and drainage.

• Describe the technique of incision and drainage.

• Outline the appropriate evaluation of the potential complications of incision and drainage.

• Describe interprofessional team contributions to the comprehensive management of patients with skin and soft tissue abscesses.

Access free multiple choice questions on this topic.

Introduction

Incision and drainage (I&D) is a widely used procedure in various care settings, including emergency departments and outpatient clinics. It is the primary treatment for skin and soft tissue abscesses, with or without adjunctive antibiotic therapy. This activity will focus specifically on its use in the management of cutaneous abscesses. Based on 2013 data from the CDC, cutaneous abscesses accounted for about 2% of all presentations to the emergency department. The same data reports that 0. 9% of all patients who presented to the emergency department underwent incision and drainage. In the pediatric population, the incidence of skin and soft tissue infection (SSTI) has increased, and hospitalization due to SSTI doubled in the last 20 years.[1] As such, being well versed in I&D is essential for clinicians in both the adult and pediatric care settings.

Anatomy and Physiology

Cutaneous abscesses are localized collections of pus that occur within the dermis and subcutaneous space. They occur virtually anywhere on the body; however, common locations for an abscess to develop are the groin, buttocks, axillae, and extremities. 

In most cases, a cutaneous abscess can be diagnosed clinically on the basis of physical examination alone. The classic characteristics of an abscess are erythema, induration, tenderness to palpation, and fluctuance. Care must be taken to differentiate between cellulitis and abscess, as the treatment for cellulitis is antibiotic therapy without drainage. Typically an abscess will be fluctuant on exam, whereas this is not a feature of cellulitis. In cases of equivocal clinical findings, ultrasonography can be used to assess for the presence of an abscess, in addition to providing information on size and location.

Studies have been done to compare the use of physical exam and ultrasonography in the detection of an abscess. A prospective study in the pediatric population revealed that in cases when abscesses could not be diagnosed clinically, bedside ultrasound had higher sensitivity and specificity than the exam alone.[2] In the same study, there was no difference in sensitivity and specificity between exam and ultrasound when the abscess was diagnosed clinically. In terms of differences in outcomes (i.e., treatment failure), there is a study that assessed treatment failure rates ten days after I&D.[3] Patients who were diagnosed by ultrasound in addition to physical exam had lower treatment failure rates ten days after I&D in comparison to patients who were evaluated by exam alone. This suggests that performing an ultrasound to evaluate for abscess improves treatment outcomes; this is, of course, reliant on the availability of experienced technicians and radiologists.

Indications

Most patients with an abscess should have incision and drainage performed, as antibiotic therapy alone is not sufficient for treatment. In cases of small fluid collections, conservative management with antibiotics, in addition to the manual expression of pus can be considered.

Contraindications

Possible contraindications to bedside incision and drainage include large and deep abscesses, the presence of a pulsatile mass at the site of infection, proximity to the vasculature and nervous structures, the presence of a foreign body, and particular locations of an abscess.

Certain locations on the body make bedside incision and drainage more technically difficult to perform, whether due to the inherent sensitivity of the area (e.g., the palms, soles, and face) or associated complications. Examples of locations that warrant evaluation by surgery due to a high potential for complications include perirectal and periareolar abscesses, which could be complicated by fistula formation. An otolaryngologist should evaluate neck abscesses that could potentially have developed from preexisting cystic lesions.

Consider also the need for prophylactic antibiotics in patients with abnormal or artificial heart valves as this may delay the procedure. Additionally, it is prudent to inquire about underlying bleeding disorders and to determine a history of allergy to lidocaine, epinephrine, or latex if using latex gloves.

Equipment

Generally, the following sterile equipment is required for a safe and successful procedure: cleansing agent (typically povidone-iodine or chlorhexidine), a local injectable anesthetic agent (1% or 2% lidocaine, lidocaine with epinephrine, or bupivacaine), 5 to 10 mL syringe with 25 to 40 gauge needle, 4×4 gauze, scalpel blade with a handle, curved hemostat, normal saline solution with large syringe/splash guard/bowl for irrigation, packing material (iodoform or plain gauze), swabs for wound culture (if desired), scissors and tape for dressing the wound. [4]

Incision and drainage is a painful procedure that, in addition to local anesthetic, may also require oral or even parenteral analgesia.

Personnel

The procedure is relatively simple and is often performed by a single clinician.

In certain situations, the presence of support staff may be warranted. In the pediatric population, child life services can play a critical role in facilitating a successful procedure. Child life specialists are professionals whose role is to provide emotional support to children and families in a health care setting. A recent study published in pediatric emergency medicine evaluated the impact of child life on the emotional response of pediatric patients who underwent laceration repair in the emergency department.[5] Comparing children who underwent the procedure without the presence of these specialists with children assisted by child life, those with support were found to have less emotional distress during the procedure.

Preparation

Informed consent from the patient or the patient’s legal guardian must be obtained before the procedure. Risks including bleeding, pain and possible scar formation should be relayed. The verification of tetanus immunization status is also an important step in preparation.

The clinician performing the procedure should follow universal precautions that include wearing a gown, gloves, and a facemask or goggles for protection. Although I&D is not considered a sterile procedure (given that the area of interest is already infected), it is prudent to practice sterile precautions.

Technique or Treatment

Holding the scalpel with a steady grip, an incision is made directly over the center of the abscess until pus is expressed. The incision should be made parallel to skin tension lines in order to prevent scar tissue formation. A curved hemostat can then be used for blunt dissection to further disrupt loculations within the infected cavity. Manual expression can be used to facilitate drainage as well. After the abscess is drained, the wound should be copiously irrigated with sterile normal saline solution. Wound packing is not recommended for abscesses that are 5 cm or less in diameter, as it has not been shown to affect outcomes and may contribute to increased pain.[6][7] Furthermore, packing has not been shown to reduce the risk of abscess recurrence.[8]

The next step is to cover the site with sterile dressing and tape. A follow-up visit is advised 2 to 3 days after the procedure for removal of the packing. Wounds are then left to close by secondary intention.

An alternative to I&D is needle aspiration, though this is much less commonly used, given that it is both more invasive and less effective than I&D. In a randomized clinical control trial comparing outcomes with I&D to ultrasound-guided needle aspiration, the overall success of producing purulent drainage with needle aspiration was 26% compared to an 80% success rate in patients who underwent I&D.[9]

Another alternative to conventional incision and drainage is the loop drainage technique, which may reduce pain and scarring at the site of infection. Studies suggest that loop drainage is associated with a lower failure rate than conventional therapy, although it is not yet a widely used procedure.[10]

Complications

Typically I&D is well tolerated with pain being the most common complication. Inadequately drained abscesses can lead to the extension of the infection into adjacent tissues and worsening of clinical status.

Clinical Significance

As stated, incision and drainage is a common procedure in a variety of care settings. It is the standard of treatment for subcutaneous abscesses, with or without adjunctive antibiotic therapy.

Enhancing Healthcare Team Outcomes

The successful treatment of skin abscesses is not limited to clinician proficiency in performing incision and drainage. Often patients will understandably have questions regarding disease recurrence and prevention, and there is a significant amount of research to address these topics.

Although bacterial etiology was not discussed in this article, skin and soft tissue infections are many times caused by Staphylococcus aureus, with the prevalence of MRSA increasing.  IDSA (Infectious Diseases Society of America) guidelines on the management of skin and soft tissue infections due to MRSA discuss measures to prevent recurrence. These guidelines are derived from important research performed by not only physicians but other integral members of the healthcare team as well. There have been multiple publications by nursing on the subject of recurrence prevention.[11][12] The results of these studies support IDSA guidelines of proper hand hygiene and post-drainage MRSA decolonization with mupirocin. It is important to recognize that standards of care are the result of interprofessional efforts.

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

Figure

Diabetic Foot Infection
Status post incision and drainage with insertion and antibiotic beads. Contributed by Mark A. Dreyer, DPM, FACFAS

References

1.

Lopez MA, Cruz AT, Kowalkowski MA, Raphael JL. Trends in resource utilization for hospitalized children with skin and soft tissue infections. Pediatrics. 2013 Mar;131(3):e718-25. [PMC free article: PMC3581839] [PubMed: 23439899]

2.

Marin JR, Dean AJ, Bilker WB, Panebianco NL, Brown NJ, Alpern ER. Emergency ultrasound-assisted examination of skin and soft tissue infections in the pediatric emergency department. Acad Emerg Med. 2013 Jun;20(6):545-53. [PMC free article: PMC3682683] [PubMed: 23758300]

3.

Gaspari RJ, Sanseverino A, Gleeson T. Abscess Incision and Drainage With or Without Ultrasonography: A Randomized Controlled Trial. Ann Emerg Med. 2019 Jan;73(1):1-7. [PubMed: 30126754]

4.

Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M. Videos in clinical medicine. Abscess incision and drainage. N Engl J Med. 2007 Nov 08;357(19):e20. [PubMed: 17989377]

5.

Hall JE, Patel DP, Thomas JW, Richards CA, Rogers PE, Pruitt CM. Certified Child Life Specialists Lessen Emotional Distress of Children Undergoing Laceration Repair in the Emergency Department. Pediatr Emerg Care. 2018 Sep;34(9):603-606. [PubMed: 30045353]

6.

Leinwand M, Downing M, Slater D, Beck M, Burton K, Moyer D. Incision and drainage of subcutaneous abscesses without the use of packing. J Pediatr Surg. 2013 Sep;48(9):1962-5. [PubMed: 24074675]

7.

O’Malley GF, Dominici P, Giraldo P, Aguilera E, Verma M, Lares C, Burger P, Williams E. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med. 2009 May;16(5):470-3. [PubMed: 19388915]

8.

Kessler DO, Krantz A, Mojica M. Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department. Pediatr Emerg Care. 2012 Jun;28(6):514-7. [PubMed: 22653459]

9.

Gaspari RJ, Resop D, Mendoza M, Kang T, Blehar D. A randomized controlled trial of incision and drainage versus ultrasonographically guided needle aspiration for skin abscesses and the effect of methicillin-resistant Staphylococcus aureus. Ann Emerg Med. 2011 May;57(5):483-91.e1. [PubMed: 21239082]

10.

Gottlieb M, Peksa GD. Comparison of the loop technique with incision and drainage for soft tissue abscesses: A systematic review and meta-analysis. Am J Emerg Med. 2018 Jan;36(1):128-133. [PubMed: 28917436]

11.

Tidwell J, Kirk L, Luttrell T, Pike CA. CA-MRSA Decolonization Strategies: Do They Reduce Recurrence Rate? J Wound Ostomy Continence Nurs. 2016 Nov/Dec;43(6):577-582. [PubMed: 27820584]

12.

Rosenberg K. Decolonization Reduces Risk of Postdischarge MRSA. Am J Nurs. 2019 Jun;119(6):69. [PubMed: 31135441]

Disclosure: Alyssa Pastorino declares no relevant financial relationships with ineligible companies.

Disclosure: Melissa Tavarez declares no relevant financial relationships with ineligible companies.

Drainage of abscesses of the female genital organs

The most common localization of abscesses in the vulva is an abscess of the Bartholin gland. Inflammation of the Bartholin’s gland leading to an abscess is most often the result of a gonorrheal infection. Gonorrheal inflammation affects almost exclusively the excretory duct of the gland; the gland itself remains unaffected. The inflamed excretory duct is filled with pus, its opening swells and sticks together, as a result of which the pus cannot pour out. The accumulated pus stretches the excretory duct of the gland and turns it into a false abscess. Suppuration usually does not occur in the surrounding connective tissue. If pyogenic microorganisms join the gonococci, then the gland itself can fester, and then a true abscess of the Bartholin gland is formed. The disease occurs when infectious agents enter the Bartholin gland. The most common are sexually transmitted diseases: gonorrhea, trichomoniasis, chlamydia.

There are also bartholinitis caused by other pathogens:

• staphylococci,
• streptococci,
• E. coli,
• candida
• and others.

However, most often the disease is caused by an association of two or three infections. As a rule, pathogens enter the duct of the Bartholin gland from the urethra or vagina during urethritis and / or colpitis. However, sometimes it is possible for an infection to enter directly into the gland itself with a blood or lymph flow. Non-compliance with the rules of personal hygiene (especially during menstruation) contributes to the infection entering directly into the duct of the gland. “for infection. Wearing tight underwear disrupts the normal outflow of gland secretions, so it stagnates, creating ideal conditions for a pathogen to enter the gland duct. A promiscuous sex life at times increases the likelihood of infection with sexually transmitted diseases. The presence of foci of chronic infection (caries) in the body , pyelonephritis). In this case, pathogens enter the Bartholin’s gland with blood or lymph flow. Impairment of the immune system, general or local hypothermia, lack of vitamins leads to a decrease in protective factors in the body. This contributes to the entry of infectious agents both directly into the gland itself and into its duct. Surgical interventions on the urogenital area (for example, abortion) performed in violation of health standards during manipulation, as well as with non-compliance with the rules of the postoperative period.

Types and symptoms

The disease begins acutely: there is severe pain in the region of the labia majora, in which an abscess has developed. The pain intensifies when walking, sitting, during intercourse and passing stools. The body temperature rises to 38-39 ° C, fatigue, weakness and chills appear. There is swelling of the labia majora on the side of the lesion. Moreover, sometimes it is so pronounced that it closes the entrance to the vagina. The appearance of a fluctuation (softening of the swelling) indicates that a true abscess of the Bartholin gland has developed, and a purulent capsule has formed in its cavity. The woman’s condition worsens: the body temperature rises to 40 ° C, phenomena of intoxication (weakness, chills, headache). Pain in the region of the labia majora, in which the cyst has formed, intensifies, acquiring the character of a constant pulsating.

Local changes

Severe swelling (edema) of the labia majora on the side of the lesion, which sometimes reaches up to 5-7 cm in diameter. The abscess can open on its own. At the same time, the general condition of the woman improves: the body temperature drops, swelling and pain decrease.

Diagnosis

Recognition of a typical false abscess is not difficult. An abscess differs from a Bartholin gland cyst in pain and soreness when palpated, redness in the area of ​​​​the opening of the excretory duct of the gland. This redness is often accompanied by swelling of the skin. Furuncles, sometimes localized in this area, rarely reach such a size as an abscess of the Bartholin gland; in addition, boils lie more superficially. With a hematoma, which has a characteristic color and is the result of an injury, as evidenced by anamnestic data, it is, of course, difficult to mix an abscess. In the same way, it is difficult to mistake a hernia of the pudendal lip for an abscess of the Bartholin’s gland.

Treatment

Abscess opening technique. The preparation of the operating field is normal. The hair on the external genital organs is shaved, the vagina is washed with some disinfectant solution (potassium permanganate solution, etc.) and, in order to avoid contamination with pus, it is tamponed with a strip of sterilized gauze. For anesthesia, we usually use ether or chloroethyl stunning. The incision area is smeared with iodine tincture. The incision should be made large and brought to the lower pole of the abscess, otherwise pockets will remain in which pus will accumulate, resulting in a purulent fistula that does not heal for a long time. The incision is made in the place of the clearest fluctuation, where the tissue covering the abscess is most thinned. After the pus has flowed out, the abscess cavity is sprinkled with white streptocide or wiped with a small tupfer moistened with iodine tincture; then a strip of gauze or a thin rubber tube is inserted into the cavity so that the hole does not close prematurely. At the end of the operation, the end of the gauze strip is removed, and a day later it is completely removed. A gauze and cotton pad is placed in front of the vulva to absorb the pus flowing from the wound. Applying a bandage is unnecessary. The drainage tube is replaced after 2 days with a fresh gauze strip or a drainage tube of a smaller diameter. It is necessary to ensure that the hole does not stick together before the granulations fill the abscess cavity. Satisfactory results are obtained by Vishnevsky’s ointment. Gauze turunda, impregnated with Vishnevsky’s ointment, can also be applied immediately after incision of the abscess of the Bartholin gland. If the inflammation recurs or a purulent fistulous tract remains for a long time, then a radical operation is necessary, i.e. removal of the gland along with its excretory duct.

Consequences of non-intervention

Acute or subacute process may result in complete recovery. However, the most common outcome is the transition to chronic bartholinitis or the formation of a cyst of the large gland of the vaginal vestibule. Therefore, a timely appeal to a specialist will allow time to stop the inflammatory process and determine the causative agent of the infection.

Outpatient surgeries – Acute bartholinitis (surgical treatment) close to home

Bartholin gland cyst.

Bartholin’s glands are located at the entrance to the vagina in women, one on each side. They are small, and normally not noticeable and not felt. The function of the Bartholin glands is to release fluid to the mucous membranes, the inner surfaces of the labia minora.

Bartholin’s cyst develops when the exit channel in the gland is blocked. Usually this happens only with one of the two glands. The fluid that is produced in the gland begins to accumulate inside. As a result, the gland enlarges and forms cysts. If the cyst becomes infected, an abscess occurs.

Bartholin gland abscess can be caused by almost any bacteria. Most often, these are microorganisms that cause sexually transmitted diseases – chlamydia and gonorrhea, as well as bacteria that live in the gastrointestinal tract (E. coli). It is not uncommon for more than one type of microorganism to be found in an abscess.

Bartholin gland cyst symptoms.

Bartholin gland cyst causes swelling of the labia on one side, near the entrance to the vagina.

The cyst itself does not usually cause much pain. And if such pain appears, this may indicate the development of an abscess.

Bartholin gland abscess causes severe pain in addition to swelling of the gland, signs of intoxication (fever, weakness, lethargy, lack of appetite) may be present.

The swollen area becomes very sensitive and the skin turns red. Walking and sitting can be very painful.

Diagnosis of a Bartholin’s cyst. In our Paracelsus Medical Center, in one day you can undergo all the necessary examinations to make this diagnosis and prepare for surgical treatment!

A physical examination is required to make a diagnosis of a Bartholin’s cyst or a Bartholin’s abscess.

Sometimes a test is done to determine the type of bacteria that caused the infection and to check if the patient has a sexually transmitted disease (gonorrhea or chlamydia). For analysis, a smear is simply taken with a cotton swab from the contents of an opened abscess or other area (cervix, for example). The result of these tests may indicate the need for antibiotic treatment.

Surgical treatment of acute bartholinitis (abscess of the Bartholin gland cyst).

In our MC Paracel, surgical treatment of abscess of the Bartholin gland is carried out on the day of the patient’s initial treatment, if necessary, a certificate of incapacity for work is issued.

Abscesses and large, painful cysts often require surgical drainage. An abscess is an infection in a confined space, and antibiotics may not work. Therefore, treating a Bartholin gland abscess almost always requires releasing the fluid inside it (opening a Bartholin gland abscess).

Local anesthesia is used to drain an abscess.