A 25 year-old female, otherwise healthy, comes into the office complaining of severe rectal and perianal pain on defecation for the past 2 weeks. She notices a minimal amount of blood on the toilet paper when wiping on occasion. Her chief complaint is extreme pain on passing her stools, every 1-2 days. She has no diarrhea or change in bowel habits.

Do you have any other questions for her?

What is the differential diagnosis?

What will you be looking for on physical exam?

What is the treatment?

Further questioning should include any other significant past medical history, family history (specifically of inflammatory bowel disease), medications, and prior history of any stooling problems. This patients has a non-contributory family history, takes oral contraceptives only, and has had no previous problems with her bowel habits. She is otherwise healthy.

The differential diagnosis for this patient’s history includes anal fissure, Inflammatory Bowel Disease (IBD--Crohn’s disease or ulcerative colitis), anorectal abscess, thrombosed external hemorrhoid, an STD such as herpes, and levator syndrome.

An exam of the anorectal region should always be performed in the left lateral decubitus, or lateral Sims, position. This is the most gentle and patient-friendly way to perform the exam. A sheet is placed across the patient’s waist. This patient’s exam appears normal with the exception of a small superficial tear at the anal verge.

Inspection should be done first, for any external lesions. Anoscopy is a very easy way to perform a thorough anorectal exam and all family physicians should be adept at this procedure. The device is adequately lubricated, then gently placed in the anus and slowly advanced with the obturator in place. With an adequate light source, one can see the distal 4-8 cm of the rectum. After removing the obturator, the device is slowly removed during inspection, while one carefully looks for hemorrhoids, ulcerative lesions, etc.

A patient with a suspected anal fissure generally should not undergo an exam with an anoscope because of the extreme pain it can cause (with a fissure). If indicated, topical lidocaine jelly can be used as the lubricant to lessen the discomfort. You elect to defer anoscopy with this patient.

Treatment for uncomplicated acute anal fissures includes stool softeners, warm sitz baths, and topical hydrocortisone cream, applied 2-3 times per day at the anal verge. You recommend these measures for the patient and she improves in the coming days.

Chronic, recurrent, or multiple anal fissures necessitates a search for underlying causes, such as inflammatory bowel disease, and referral to a colorectal surgeon for evaluation for a possible lateral internal sphincterotomy and anal dilatation.

A 40 year old man presents to the clinic with a 2 day history of perianal irritation and severe pain. He thinks there is a ‘bump’ near his anus. The pain is excruciating, and he can hardly sit down without extreme discomfort. He has noticed minimal blood on the toilet paper when wiping, and describes no change in his bowel habits.

Any further historical questions?

What is the differential diagnosis?

Physical exam findings you may expect?

Treatment?

Further questioning should include any history of prior similar symptoms, change in stooling habits, other medical problems, medications, and family history. This patient has never had these symptoms before, has solid bowel movements every 1-2 days, has hypertension which is well-controlled on hydrochlorothiazide, and a non-contributory family history.

The differential diagnosis includes anorectal fissure, thrombosed external hemorrhoid, with or without internal hemorrhoids, puritis ani, levator syndrome, inflammatory bowel disease, and anorectal abscess.

The patient is placed in the left lateral decubitus position with a sheet for a complete anorectal exam. Upon inspection, you visualize 2-3 cm bluish-discolored firm papule, exquisitely tender to palpation, at the anal verge. Additional anoscopic exam is negative, as normal rectal mucosa is visualized.

The definitive treatment for thrombosed external hemorrhoids is surgical excision in the office. The actual etiology of hemorrhoids is unclear, but when these dilated and enlarged veins in the anal area form below the dentate line, they can become thrombosed over time and present as a very painful small perianal mass. Oftentimes, conservative management with warm sitz baths, stool softeners, and analgesics (often narcotics are needed) will alleviate the pain and thrombosis. However, with this approach, the risk of recurrence of the thrombosed hemorrhoid still exists.

To excise the thrombosed external hemorrhoid, an assistant lifts the gluteus maximus to aid in visualization for the procedure. The base of the hemorrhoid is then infiltrated with lidocaine with epinephrine (to aid in hemostasis) for proper anesthesia. The lesion is then excised completely using an elliptical excision, also removing the overlying skin. Care is taken not to extend the incision past the anal verge. Direct pressure plus a folded gauze pad usually provide adequate hemostasis; sutures are rarely needed and cause more post-procedure pain. It is imperative to provide a 1-2 day supply of narcotic analgesics, as the area is quite tender after the anesthetic wears off. After roughly 1-2 days of bedrest, most patients feel well enough to return to work, etc.

You perform the above procedure on the patient without incident and his problem resolves.

A 58 year old man presents with a one month history of hematochezia (bright red blood per rectum), only associated with bowel movements. He denies pain. The blood is on the toilet paper and some in the toilet with his stool; he is unable to quantify the amount. He is concerned, although he states he has had intermittent blood associated with bowel movements without pain "for years."

What else is important in the history?

What is the differential diagnosis?

What is important to look for on exam?

What is the treatment or further evaluation indicated?

Being over 50 years old, it is very important to consider colorectal carcinoma in a patient with hematochezia. The patient should be questioned for symptoms of fatigue, weight loss, appetite changes, change in bowel habits, family history of colorectal cancer, etc. He should also be questioned as to whether or not he has ever had colorectal cancer screening of any kind. Medications and past medical history need to be reviewed, along with a thorough review of systems. This patient clearly has some sort of bleeding from the gastrointestinal tract, and its source must be found.

The remainder of the history you obtain as above is negative; he otherwise feels well, ROS is negative, he takes no NSAIDS, and takes acetaminophen occasionally for back pain. He has never had colorectal cancer screening that he can recall.

The differential diagnosis in this patient is broad, and includes cancer, polyps, other benign masses intermittently bleeding in the colon, internal hemorrhoids, and IBD. Without pain as a presenting symptom, fissures, thrombosed external hemorrhoids, and anorectal absecesses are all less likely.

General and abdominal exams are non-contributory. Exam of the external anorectal region is negative. On anoscopy, you see 2 large internal hemorrhoids, that actively bleed a bit during the exam. They do not protrude through the anal canal.

It is very important to differentiate internal from external hemorrhoids. Generally, the only symptom with internal hemorrhoids is bleeding, and they do not present with pain. If they are large enough, they will prolapse through the anal canal either with straining or intermittently, and can either still be able manually reduced (third- degree hemorrhoids) or prolapse constantly and be non-reducible (fourth-degree hemorrhoids).

There are several treatments available for internal hemorrhoids, and a common and safe office practice for the primary care provider is rubber band ligation.

Despite this patient has a clear source for his rectal bleeding (obvious internal hemorrhoids on office exam), he must still be evaluated more thoroughly for colorectal cancer. The US Preventative Service Task Force recommends colorectal cancer screening in all individuals beginning at age 50, and at age 40 with a positive family history. Colorectal cancer is the second highest cause of cancer death in the US.

There are several acceptable methods for colorectal cancer screening, and recommendations change fairly regularly. Currently, screening colonoscopy or flexible sigmoidoscopy at recommended intervals, or fecal occult blood testing annually (with follow up colonoscopy if positive) are currently all accepted methods of screening and have all been shown to reduce colorectal cancer mortality.

See the following link to Primary Care, "Office Management of Common Anorectal Problems," March, 1999, for further in-depth discussion of all these and more issues important to primary care providers regarding colorectal problems in general.

Examination and Diseases of the Anorectum  (MDCONSULT)