Gout is a common disease caused by purine metabolism disorder, leading to elevated serum uric acid levels and subsequent deposition of monosodium urate (MSU) crystals in joints and soft tissues, which triggers inflammatory responses. Its classic manifestation is acute arthritis, most commonly affecting the first metatarsophalangeal joint (MTP1), ankle region, and knee joint. However, as the disease progresses, gout can lead to chronic joint destruction and tophi formation, and in severe cases, bone erosion and functional impairment [1]. Nevertheless, when gout involves rare sites such as metatarsal epiphyses, the acromioclavicular joint, the sinus tarsi, or the Perianal region, its imaging features often overlap with those of malignant tumors or infectious osteopathies or infectious mass, leading to misdiagnosis and even unnecessary invasive procedures or surgeries [[2], [3], [4]]. However, I have found no reports regarding perianal tophi. Perianal gouty tophi, especially when large or associated with local infection/acute flares, are uncommon in clinical practice and can be easily misdiagnosed as perianal abscesses, hidradenitis suppurativa, or even tumors. This article introduces a case where perianal tophi was misdiagnosed as perianal abscess, aiming to enhance the understanding of this disease, minimize the misdiagnosis rate and hopefully provide references for clinical diagnosis and treatment. Serum uric acid is an important indicator for diagnosing gout. However, in this case, the value of serum uric acid was normal, which indicates that for some patients, the level of serum uric acid is often inconsistent with the severity of tophi. This point deserves the attention of primary care physicians during the process of diagnosis and treatment.