62. Anorectal pain

Question 1

Causes of anorectal pain.

a) With bleeding
b) Without bleeding

Answer 1

a) Thrombosed haemorrhoids, anal fissure, proctitis (eg. UC/Crohn’s), rectal/anal carcinoma, trauma
b) Pilonidal sinus/abscess, perianal abscess, perianal fistula (Crohn’s), rectal prolapse

Question 2

Anal fissure.

a) Risk factors
b) Clinical features
c) What symptoms should you enquire about to rule out red flags?
d) Confirming diagnosis
e) Differentials
f) Management

Answer 2

a) Constipation (hard stool tears the anal mucosa as it is passed), IBD (ulceration), STI, rectal malignancy
b) Pain on defecation (like passing shards of glass), fresh blood passed PR
c) Abdominal pain; changes in bowel habit; weight loss; abdominal/anorectal mass; rectal discharge
d) Examination of the buttocks to confirm tear in anal mucosa; do not PR unless sinister cause suspected (as will be very painful)
e) Haemorrhoids (thrombosed - painful), proctitis (UC), abscess, fistulae

f) - Conservative: regular fluids, good fibre intake, laxatives as required, pain relief, warm baths
- Medical: 1st line topical GTN or lidocaine
- Medical 2nd line: topical nifedipine, or botulinum
- Surgical (eg internal sphincterotomy)

Question 3

Haemorrhoids.

a) What are they? Give the 2 basic types
b) Grading on examination
c) Clinical features
d) Risk factors
e) Appearance of normal vs thrombosed haemorrhoid
f) Management of suspected haemorrhoids (who should be referred?)

Answer 3

a) Abnormally enlarged vascular cushions: internal (above dentate line) and external (below dentate line)
b) Internal: grades 1-4 based on degree of prolapse

c) Internal: painless (unless strangulated) fresh bleeding
External: PR bleed, may be painful or itchy

d) Constipation, prolonged straining and time on the toilet, increased abdominal pressure (e.g. coughing, obesity, ascites, pregnancy

e) Normal: bluish, bulging vessels covered by mucosa
Thrombosed: purple, swollen, acutely tender

f) - Confirm with anorectal examination including PR (note: internal haemorrhoids may not be visible or felt)
- Refer for LGI endoscopy if: a change in bowel habit, tenesmus symptoms, abdominal pain, other LGI symptoms or haemorrhoids not clinically apparent
- Increase fluids and fibre; manage constipation
- Pain relief (simple analgesia/ topical lidocaine)
- Rubber band ligation
- Surgical: haemorrhoidectomy

Question 4

Pilonidal sinus.

a) Cause and risk factors
b) Clinical features
c) Investigations to exclude other pathology
d) Management

Answer 4

a) Loose hairs driven into natal cleft, causing sinus tract inflammation. Risks: male, hirsutism, obesity
b) A hole in the natal cleft; may be asymptomatic or may be painful, red, bleeding or leaking pus
c) CRP/ESR (eg IBD)

d) - Asymptomatic/non-infected: reassure, good perinanal hygiene, buttock hair removal advice
- Pain relief/ anti-inflammatories
- Infected: antibiotics
- Abscess/discharging: surgical excision and drainage