5. Anorectal pain

Question 1

Name causal conditions of anorectal pain (19)

Answer 1

• Anorectal Disease
  
  • Abscess
  • Fistula
  • Fissure
  • Hemorrhoids (internal and external)
  • Rectal prolapse
  • Chemotherapy
  • Neuropathy
• De matologic
  
  • Psoriasis
  • Contact/atopic dermatitis
  • Malignancy
  • Ulcer
• Infections
  
  • Bacterial
  • Fungal
  • Viral
  • Parasitic
• Other
  
  • Psychological
  • Coccygeal pain
  • Trauma
  • Pelvic floor muscle syndrome

Question 2

Name Infectious Agents possible for anorectal pain (11)

Answer 2

• Sexually Transmitted
  
  • N.gonorrhoeae
  • C.trachomatis
  • HSV
  • Syphilis
• Bacteria
  
  • Salmonella
  • C.difficile
  • Shigella
  • Campylobacter
• Fungi
  
  • Tinea (ringworm)
  • Parasites
  • E.vermicularis (pinworm)

Question 3

Describe: Approach to patient with anorectal pain. (Figure)

Answer 3

Question 4

Name causes of defecation-associated pain (4)

Answer 4

• Anorectal Fistula
• Anorectal Abscess
• Anal Fissures
• External Hemorrhoids

Question 5

Describe sx/signs and management: Anorectal Fistula (5)

Answer 5

• One or more perianal openings
• palpable cord- like perianal tract
• Hx of previous abscesses
• intermittent or constant purulent or serous discharge from perianal opening
• Management: General surgery referral

Question 6

Describe sx/signs and management: Anorectal Abscess (5)

Answer 6

• Tender anorectal mass
• Fever
• Digital rectal exam reveals a tender fluctuant mass on rectal wall.
• Hx of continuous deep seated pain and rectal discomfort that worsens with ambulation or straining
• Management: Urgent general surgery referral

Question 7

Describe sx/signs and management: Anal Fissures (6)

Answer 7

• Anal canal tear along posterior or anterior midline
• bleeding
• hypertrophic papillae
• skin tags
• Hx of hard, large, painful stools, “knife-like” pain lasting up to several hours post defecation
• Management: Manage Sx

Question 8

Describe sx/signs and management: External Hemorrhoids (8)

Answer 8

• Painful, bluish perianal swellings
• skin tags
• sensation of incomplete defecation
• pruritus
• bloody stools
• or prolapsed mass.
• Hx of pregnancy, constipation, anoscopy shows anal swellings
• Management: Manage Sx. Surgical referral if refractory

Question 9

Name causes of anorectal pain with perianal rash, erythema, or lesions (6)

Answer 9

• Psoriasis
• Contact Dermatitis
• Atopic Dermatitis
• HPV
• Malignancy
• Fungal Infection

Question 10

Describe clinical presentation: Psoriasis (2)

Answer 10

• Sharply demarcated inflamed
• bright red pruritic perianal lesions

Question 11

Describe clinical presentation: Contact Dermatitis (3)

Answer 11

• Papulovesicles with surrounding erythema
• weeping and crusted lesions
• Hx suggestive of chronic contact with potentially allergic agents (e.g., latex condoms, sanitary wipes)

Question 12

Describe investigation: Contact Dermatitis (1)

Answer 12

Closed patch test

Question 13

Describe clinical presentation: Atopic Dermatitis (2)

Answer 13

• Generalized xerosis, erythematous, lichenified, pruritic patches and papules.
• Hx of asthma, allergic rhinoconjunctivitis

Question 14

Describe investigation: Atopic Dermatitis (2)

Answer 14

Antibody serology

Question 15

Describe clinical presentation: HPV (2)

Answer 15

• Single or multiple papillary eruptions
• Hx of receptive anal activity, immuno suppression

Question 16

Describe investigation: HPV (2)

Answer 16

• Acetowhitening test
• anoscopy

Question 17

Describe management: HPV (4)

Answer 17

• No cure— manage Sx
• Self-resolving
• Can use cryotherapy, topical creams, or surgical removal.
• Monitor for HPV-related cancer—anal Pap smear

Question 18

Describe clinical presentation: Malignancy (3)

Answer 18

• Ulcerating anal or perianal lesion
• Hx of bleeding, HPV infection, receptive anal intercourse, or cancer (espcially cervical, vulvar, or vaginal)
• Management: Oncology referral

Question 19

Describe clinical presentation: Fungal infection (3)

Answer 19

• Symmetric sharply demarcated erythematous rash
• Hx of recurrent anal pruritus and rash
• contact sport participation

Question 20

Describe investigation: Fungal infection (1)

Answer 20

Potassium hydroxide wet mount of scales

Question 21

Describe HX: Anorectal pain (2)

Answer 21

• Determine the onset, duration, character, localization, relieving and exacerbating factors, and Hx of similar pain
• Determine the medical Hx, with an emphasis on Hx of anorectal disease, infections, rash, receptive anal intercourse, lower GI endoscopy (colonoscopy or sigmoidoscopy), or rectal prolapse

Question 22

Describe physical exam: Anorectal pain (4)

Answer 22

• Perform a complete abdo examination in addition to a perineal and digital rectal exam
• Inspect the perineum for signs of drainage, skin breakdown, and external skin tags
• Palpate the rectum for tenderness, masses (solid or fluctuant), and bleeding
• If the patient is in too much pain to be examined, an exam under anesthesia is sometimes required

Question 23

Describe investigations: Anorectal pain (2)

Answer 23

• No routine blood work is required.
• Colonoscopy or sigmoidoscopy offers an opportunity to visualize and biopsy any lesions contributing to anorectal pain.

Question 24

Describe management of hemorrhoids (3)

Answer 24

• Oral fiber intake, stool softeners, or supplements
• Toilet retraining
• Treatment of underlying disease