Causes Of Anorectal Pain can be classified into acute and chronic, following are the major causes and history and physical examination points to differentiate among them:
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 below the dentate line, where
sensation is of the somatic type. Solitary rectal ulcer may present
with pain but more usually presents with bleeding PR, passage of
mucus and difficulty with defecation. Chronic perianal sepsis may
be the presenting symptom of Crohn’s disease or TB. These diseases
may already be manifest at other sites of the body. Rarely lesions of
the cauda equina may cause anal pain.
Inspection may reveal a chronic fissure-in-ano, perianal haematoma,
thrombosed piles or a tumour growing out of the anal canal.
A tense, red, tender area may be present, representing a perianal
abscess. A fullness in the buttock with redness may indicate a large
ischiorectal abscess. A digital rectal examination should be carried
out unless the diagnosis is obvious. With gonococcal proctitis,
proctoscopy may reveal pus and blood in the rectal ampulla with
oedematous and friable mucosa. The presence of vesicles in the anal
area will suggest herpes. Solitary rectal ulcer is usually diagnosed
on sigmoidoscopy when redness and oedema of the mucosa is seen,
usually, but not always, in association with frank ulceration. If a
cauda equina lesion is suspected, a full neurological examination
should be carried out. No abnormality is usually found with
WCC ↑ infections, e.g. abscess. ESR ↑ Crohn’s disease, TB and
Sepsis may be a presentation of diabetes mellitus.
Haemorrhoids. Anorectal malignancy. Anorectal gonorrhoea.
Swab ↑ Gram-negative intracellular diplococci.
This may demonstrate intersphincteric abscesses or fistulae-inano.
This will delineate complex fistula problems or may indicate a
cauda equina lesion.
Antigen detection tests
Identification of virus in vesicle fluid.
For fast diagnosis of herpes.
● Recurrent perianal abscesses may be the first
presentation of diabetes. Ask about thirst and
● Recurrent perianal problems, especially fissures in
unusual places, may be a presentation of Crohn’s
● Do not treat perianal abscesses with antibiotics.
Perianal abscesses should be incised and drained.
Failure to do so may result in development of a
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