Chapter 41 Anorectal Pain in a 45-Year-Old Male (Case 26)
PATIENT CARE
History
• Consider the nature, duration, location, and type of pain. Is pain associated with defecation? Is bright red blood present on tissue paper or in the toilet bowl?
• A thrombosed hemorrhoid presents with acute onset of continuous anal pain, unrelated to defecation and often associated with a small, discolored, hard lump the size of a pea.
• Suspect an anal fissure if pain is experienced during defecation and also associated with some degree of bleeding.
• A firm tender swelling in the perianal area, worsening over a few days, suggests a perirectal abscess.
• Anal fistula, often seen with a previous hx of an anorectal abscess, causes pain/discomfort and a persistent discharge.
• Protrusion of a “reddish-like” mass following defecation and complaints of incontinence raise the suspicion for rectal prolapse.
Physical Examination
• Four basic approaches to a good rectal examination include:
1. Proper positioning in either the prone-jackknife position, the knee-chest position, or the left lateral decubitus position. The least embarrassing and most patient-accepted position is the left lateral.
2. Inspect the anal area for hemorrhoids, a fistula, or prolapse. Pain on inspection is often associated with a thrombosed hemorrhoid, fissure, or abscess. Evaluation of the perianal skin and anal opening, while having the patient perform a valsalva maneuver, may provide further valuable information.
3. Palpation with a water-soluble lubricant applied to a gloved index finger aids in examination of the rectum and its surrounding structures, including assessment of sphincter tone and contractility. Testing for occult fecal blood is appropriate when stool is present on the examining index finger.
4. Anoscopy or proctosigmoidoscopy (if available during examination) offers the best means to evaluate hemorrhoids and other lesions of the anal canal not palpated on digital examination. If a patient has a fissure, digital exam and use of instruments should often be avoided since it will cause excessive pain and discomfort.
Tests for Consideration
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| $135 |
| Clinical Entities | Medical Knowledge |
|---|---|
| Hemorrhoids | |
| PΦ | Hemorrhoids can be either internal or external. When the cushions of the subcutaneous tissues of the anal canal become dilated (seen above the pectinate line) internal hemorrhoids develop. Abnormal dilatation of the veins surrounding the anus (seen below the pectinate line) is consistent with external hemorrhoids. |
| TP | Internal hemorrhoids are usually painless and associated with bleeding. Externals are associated with pain and itching and may cause difficulty with anal hygiene. |
| Dx | Dx of internal hemorrhoids is made by anoscopy or proctoscopy. |
| External hemorrhoids are often visualized on inspection. | |
| Tx | Tx is initially medical, using sitz baths, stool softeners, and dietary modifications. Thrombosed external hemorrhoids causing severe pain can be treated operatively with evacuation of clot and excision of the hemorrhoid. Internal hemorrhoids can be treated with band ligation, which causes necrosis and eventual sloughing. External hemorrhoids can also be removed by performing a surgical hemorrhoidectomy. See Sabiston 46, 51; Becker 21. |
| Fissure | |
| PΦ | A fissure is a tear in the anal mucosa. An acute fissure usually heals with conservative therapy. A chronic fissure has the internal anal sphincter exposed in the base of the tear, and results in spasm of the smooth muscle that inhibits healing of the fissure because of decreased perfusion—an ischemic ulcer. |
| TP | Pain during or immediately after a bowel movement. Patients often describe a “knife-like pain” and defecating is like “passing broken glass.” Bright red blood often on toilet paper. Patients with chronic fissures often have pain from the spasm, which can last for hours. |
| Dx | The most common location is in the posterior midline. The dx is made by careful effacement of the anus between two fingers to expose the ulcer. Patients are frequently too uncomfortable to undergo rectal examination. |
| Tx | Fissures are often managed nonoperatively with warm sitz baths, dietary bulking agents, and topical smooth muscle dilators like nitroglycerin or nifedipine ointment. Fissures should heal within 6 weeks. Operative management is reserved for chronic fissures. Lateral internal sphincterotomy is the procedure of choice, often relieving chronic sphincter spasm. See Sabiston 51, Becker 21. |
| Abscess | |
| PΦ | Abscess formation is believed to be the result of plugging of the anal ducts located around the anal canal, causing localized infection. Spread of infection can occur to the intersphincteric space as well as the perianal, ischiorectal, and supralevator spaces, causing a variety of presenting symptoms. |
| TP | Patients present with a tender, erythematous, often fluctuant mass in the anorectal area. Fever and chills can be present along with a leukocytosis. Patients with diabetes and immunodeficiency require immediate tx with antibiotics and surgical intervention. |
| Dx | Dx is usually made on anorectal examination. CT of the pelvis can be used to demonstrate supralevator extent of the abscess. Sometimes examination under anesthesia is needed to find intrasphincteric and supralevator abscesses that do not have external signs. |
| Tx | Tx depends on the location, size, and extent of the abscess. Incision and drainage with washout can often be performed at the bedside with daily local wound care. Patients with large abscesses, diabetes, and immunodeficiency syndromes are usually drained in the operating room. See Sabiston 51, Becker 21. |
| Fistula | |
| PΦ | Fistula formation is usually seen in patients with a hx of an anorectal abscess or inflammatory process. A fistula is a tract, a communication between the anal crypts and perianal skin, which develops in approximately 50% of patients after drainage of an abscess. Fistulae are classified by the course of the tract: intrasphincteric, transsphincteric, extrasphincteric, and supralevator. |
| TP | Patients often complain of swelling, pain, and discharge of mucus or foul-smelling fluid mixed with stool. |
| Dx | Dx is made by inspection and rectal examination. Use of anoscopy can help to locate the internal opening. Usually examination under anesthesia is required to identify the course of the tract and to treat. |
| Tx | Management consists of first identifying the fistula tract then performing a fistulotomy, which allows the tract to drain, heal, and eventually close. The tract can also be unroofed and drained if persistent abscess formation is present. See Sabiston 51, Becker 21. |
| Prolapse | |
| PΦ | Prolapse occurs as a result of weakness in the levator muscle anteriorly and various ligamentous structures laterally that aid in holding the rectum in place. Increased straining with defecation causes a downward vertical position of the rectum, which, when combined with muscular weakness, results in either a full-thickness prolapse seen with concentric mucosal folds or a partial-thickness prolapse characterized by radial mucosal folds. |
| TP | Patients present with pain, constipation, fecal incontinence, and gross prolapse. |
| Dx | Dx can be made by rectal examination. Having the patient strain on a commode will usually demonstrate the prolapse. |
| Tx | Nonoperative treatments include manual anal support while defecating, correction of constipation, perineal strengthening exercises, and injection of sclerosing agents. Surgical therapy includes obliteration of the pouch of Douglas, restoration of the pelvic floor, resection of bowel via a perineal versus a peritoneal approach, and suspension or fixation of the rectum. See Sabiston 51, Becker 21. |
| Squamous Cell Carcinoma | |
| PΦ | Squamous cell carcinoma is usually associated with infection with human papillomavirus (HPV) oncogenic subtypes 16 and 18 and in many cases can be thought of as a sexually transmitted disease, clinically related to the development of anal warts. Cancer development is by integration of HPV DNA into anal canal cell chromosomes. |
| TP | Patients typically present with a mass associated with bleeding and pain. It is often first misdiagnosed as a hemorrhoid. |
| Dx | Anorectal biopsy is the procedure of choice for making the dx. Biopsies of nearby enlarged lymph nodes assess regional extension. |
| Tx | The combination of radiation and chemotherapy has helped to improve survival without radical surgery. If residual tumor is present following chemoradiation, an abdominal perineal resection is performed (see discussion, Professor’s Pearls, scenario #3). See Sabiston 51, Becker 21. |
a. Impaction: Fecal impaction consists of a large mass of dry, hard stool that develops in the rectum due to chronic constipation. The stool can be so hard that a patient is unable to defecate. Watery stool from higher in the bowel may move around the mass and leak out, causing incontinence. See Sabiston 51.
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