Approach to anorectal pain

Thanks to Gabby Liu for presenting a patient with fever, anorectal pain and bleeding. Gabby gets a big shout out for presenting in report as an intern.
This is a great opportunity to highlight one of my favorite resources for outlining general approaches to all things outpatient. The American Family Physician Review Articles.
Why are they so great? 3 reasons.
1) All articles start with a list of evidence-based recommendations. They also grade evidence quality in a fancy table
2) They provide a well organized Ddx for common complaints
3) Focus on treatment as well as ddx
Ano-rectal complaints can be organized anatomically and differentiated based on whether a mass or other lesion is visible on exam
Anal causes
  • fissure
  • thrombosed external hemorrhoids
  • abscess
  • infections like…
    • viral (HSV, condyloma d/t HSV)
    • bacterial (typical bacterial organisms, gonorrhea, syphillis or chlamydia)
    • Fungal (rare in immunocompetent people)
    • parasites (pinworm, especially in children and immune competent adults)
  • cancer
  • ano-rectal presentation of IBD
  • trauma
  • anorectal fistula
Rectal causes
All of the diagnoses listed above plus special considerations of…
  • rectal prolapse
  • proctitis – usually presents with pain, tenesmus, bloody diarrhea and/or fever
    • infectious
      • gonorrhea proctitis is particularly common and very uncomfortable for patients
      • see the pearls archive for some details on LGV proctitis, which was considered in this case
    • inflammatory
    • malignant
    • irritant
      • trauma
      • radiation
      • foreign body
  • proctalgia fugax
    • sudden onset, severe rectal pain without an obvious trigger. Caused by sudden increase in internal anal sphincter tone. It’s like the esophageal spasm of the nether regions.
  • severe constipation
    • Dr Cello taught us about stercoral ulcers, where chronic constipation and hard stool causes ulceration of the rectal mucosa, leading to pain and iron deficiency anemia.
  • internal hemorrhoid (usually don’t hurt)
All after fabulous history-taking, all ano-rectal complaints should be evaluated with an abdominal exam, external anal exam, and anoscopy, if tolerated.

Fargo MV1, Latimer KM.Evaluation and management of common anorectal conditions.

Am Fam Physician. 2012 Mar 15;85(6):624-30.

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