Back-to-Basics: Rectal Pain
Approach to Rectal Pain:
· Take a good history: frequency/duration of pain, constipation, bleeding, itching, fevers?
· Examine perianal area = surrounding 5 cm around anus
- Look for erythema, bulging, drainage, abscesses, fissures (anteriorly or posteriorly), bleeding
- Palpate for tone (resting and active)
- Advanced = anoscopy (can be done bedside) or endoscopy (not in the ED)
· Differential Diagnosis:
- Thrombosed external hemorrhoids → if within 72 hours of symptoms onset, can do bedside elliptical incision and thrombectomy; if not, or if signs of necrotic tissue = surgery consult
- Perianal abscesses → look for signs of drainage, fever, areas of induration/fluctuance
- Anal canal pain = think fissures (avoid DRE), cancer, or ulceration 2/2 STI
- Anal bleeding = think fissures and cancer again, as welll as internal hemorrhoids (these don’t hurt, they bleed)
- Prolapse of rectum or of internal hemorrhoids
- Perianal drainage → fistula, pilonidal cyst, hidradenitis
- Pruritus ani if itching
- Proctalgia fugax → severe episodes of rectal pain; self-limited and last seconds to minutes, not exceeding 30 min
- Can treat with topical nitroglycerine or topical diltiazem acutely
- Usually ages 30-60 and women>men
- Pathogenesis: anal sphincter spasm, compression of the pudendal nerve
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