Churchills Pocketbook of Differential Diagnosis

B978-0-7020-3222-6.00003-1, 00003
25
SUBASH KC/NMC-15TH/2014
ANORECTAL PAIN
Anorectal pain is a common problem. The majority of patients have
an obvious cause, e.g. fissure-in-ano, perianal abscess or thrombosed
haemorrhoids.
CAUSES
ACUTE
Fissure-in-ano
Perianal haematoma
Thrombosed haemorrhoids
Perianal abscess
Intersphincteric abscess
Ischiorectal abscess
Trauma
Anorectal gonorrhoea
• Herpes
CHRONIC
Fistula-in-ano
Anorectal malignancy
Chronic perianal sepsis, e.g. Crohn’s disease, TB
Proctalgia fugax
Solitary rectal ulcer
Cauda equina lesions
•
HISTORY
Constipation with pain on defecation and blood (usually on
the paper) will suggest fissure-in-ano. A sudden onset of pain
with a tender lump in the perianal region will suggest perianal
haematoma. A past history of prolapsing piles, with failure to reduce
them, associated with pain and tenderness suggests thrombosed
haemorrhoids. Gradual onset of pain and tenderness with swelling is
suggestive of abscess formation. A careful history must be taken of
trauma. A history of anal sexual exposure will suggest gonorrhoea
or herpes. With gonorrhoea there may be irritation, itching,
discharge and pain. With herpes there will be pain and irritation.
Proctalgia fugax is diagnosed on the history of perineal pain, which
is spasmodic, the spasms lasting up to 30 min. The pain often feels
deep inside the rectum. The cause is unknown but may be related to
paroxysmal contraction of levator ani. Anorectal malignancies will be
suggested in alteration of bowel habit and bleeding on defecation.
Pain will only be apparent if the tumour involves the anal canal
Section A