FOCUS The bottom line Anorectal pain, W John Daniel bleeding and lumps Anorectal problems are frequent presentations in Background the general practice setting.1 Symptoms tend to be a The patient presenting with anal pain, anal lump or rectal combination of one or more of pain, lumps, bleeding, bleeding is a common occurrence in the general practice discharge or itch. In this article we focus on pain, lumps setting and the combination of symptoms usually gives an and bleeding. (Perinanal itch is discussed in the article indication of the most likely diagnosis. However, careful examination including digital rectal examination is always by MacLean and Russell in this issue). required. Anorectal symptoms tend to cause anxiety in the patient, often Objective related to the fear of cancer.1 The combination of symptoms This article discusses three common anorectal conditions: usually gives an indication of the most likely diagnosis (Table 1). perianal haematoma, haemorrhoids and anal fissure, and Common anorectal conditions are shown in Figure 1. briefly discusses the less common, but not to be missed conditions: anal carcinoma and low rectal carcinoma. History Discussion A careful history of the patient’s bowel habits, with particular The majority of first degree haemorrhoids can be attention to the nature of bleeding during defecation is also managed by conservative measures alone. More severe important in the differential diagnosis. degree haemorrhoids require surgical intervention with sclerosant injection, rubber band ligation or surgical • A change in bowel habit is a ‘red flag’ for colorectal carcinoma haemorrhoidectomy. Initial treatment for anal fissure • Blood mixed with faeces is associated with rectal polyps or is with a high fibre diet, faecal softeners, topical local carcinoma (also a ‘red flag’ symptom) anaesthetic gel and glycerol trinitrate ointment. Botulinim • Bright red blood on the paper or in the bowl is often associated toxin can be injected to create a chemical sphincterotomy, with haemorrhoids. allowing healing. Chronic fissures produce intense and Tenesmus (a feeling of incomplete emptying of the rectum) is constant pain in the anal region and in these cases surgical commonly associated with irritable bowel syndrome, but may also sphincterotomy is often necessary to cure the condition, indicate an abnormal mass in the rectum or anal canal.2 but can result in faecal incontinence. Anal cancer has The presence of anal pain on defecation helps to distinguish similar presentation to haemorrhoids and carcinoma of uncomplicated haemorrhoids (painless) from fissures (painful), as distal rectum can initially present with a haemorrhoid, so both can produce bright red bleeding. the possibility of anorectal cancer should be considered in any patient presenting with haemorrhoids, tenesmus and Examination change in bowel habit. Examination involves inspection of the perianal area, which may Keywords: haemorrhoids; anus diseases; fissure in ano; reveal an obvious cause such as a perianal haematoma, prolapsing anus neoplasms; colorectal neoplasms haemorrhoid, or anal fissure. Even if a potential cause is found on inspection, the general practitioner should be prepared to don the gloves and perform an anal digital examination on every patient presenting with anorectal symptoms. Patients are often apprehensive about this procedure, but gentle insertion of a well lubricated index finger can obtain a great deal of information. Reassure the patient that the procedure will be terminated in the event of excessive pain. Provided the patient does not have marked anal spasm, it may be possible to perform a rectal examination, even in the presence of a painful condition such as an anal fissure. 376 Reprinted from AUSTraLIAN FAMILY PHYSICIAN VOL. 39, NO. 6, JUNE 2010 Table 1. Likely diagnosis of anorectal pain Pain alone Pain and lump Pain, lump and bleeding Bleeding alone • Anal fissure • Perianal haematoma • Second degree haemorrhoid • Internal haemorrhoids (bright • Anal herpes • Strangulated internal (spontaneously reducing lump red bleeding separate from • Ulcerative haemorrhoid (fourth on straining) faeces in toilet bowl or on toilet proctitis degree haemorrhoid) • Third degree haemorrhoid paper) • Proctalgia fugax • Abscess (perianal or (lump prolapsing but reducable) • Colorectal polyps (blood mixed ischiorectal) • Fourth degree haemorrhoid with faeces) • Pilonidal sinus • Ulcerated perianal haematoma • Colorectal carcinoma (blood (blood on underwear) mixed with faeces) Lump alone Pain and bleeding Lump and bleeding • Anal carcinoma • Skin tags • Anal fissure • Second degree haemorrhoid • Perianal warts • Proctitis (spontaneously reducing lump • Anal carcinoma on straining) • Anal carcinoma (blood on underwear or toilet paper) tube nesting in the hollow of the sacrum and a straight instrument can injure the anterior wall of the rectum unless the proceduralist Rectal polyp visualise the lumen of the rectum throughout the procedure. The remainder of this article discusses three common anorectal Second degree Internal sphincter conditions: perianalFirst degree haematoma, haemorrhoids and anal internalfissure; internal haemorrhoid External sphincter and briefly discusseshaemorrhoid the less common but not to be missed anal Ischiorectal carcinoma and low rectal carcinoma. Third degree Dentate line abscess (prolapsed) internal Perianal Perianal haematoma (thrombosedhaemorrhoid abscess Ischiorectal fistula external pile) Rectal polyp Anal fissure A perianal haematoma is a small subcutaneous haematoma (and not Perianal haematoma Prolapsed (fourth degree) a true haemorrhoid), with a dark blue or almost black appearance, haemorrhoid Perianal haematoma Second degree Internal sphincter close to the anal verge. It results from a burst perianal vein. A First degree internal internal haemorrhoid Figure 1. Common anorectal conditions External sphincter perianal haematoma usually develops as an acute episode following haemorrhoid a heavy effort such as lifting, or coughing or sneezing andIschiorectal presents Third degree Dentate line abscess Insensitive anal mucosa (prolapsed) as a painful lump. If the patient seeks treatment within a few hours internal Anorectal junction Perianal Instrumentation to visualise the anal and haemorrhoid abscessof the onset of the symptoms, immediate relief can be Ischiorectalachieved by rectal mucosa Rectal mucosa Rectum infiltrating a small amount of local anaesthetic in the skinfistula over the An understanding of the anatomy of the anorectal region is lump, followed by a small incisionAnal fissure in the overlying skin. A recent Submucosal anal cushion Perianal haematoma Prolapsed important (Figure 2). The anal canal is roughly 5 cm in length in an blood clot is usually under pressure under (fourththin degree)skin and often ‘pops’ haemorrhoid Perianal haematoma adult. This is less than the length of an adult index finger and so out of the wound with immediate relief of the symptoms. Sphincter muscle most anal pathologies can be detected on digital examination. Examination of the anal canal with a disposable proctoscope First degree haemorrhoid Dentate line (anoscope), an instrument 7 cm in length, can access the entire anal Insensitive anal mucosa Anorectal junction canal but can only reach the most distal part of the rectum. Rectal mucosa To examine the rectum, which is 18 cm in length, requires Rectum either a rigid sigmoidoscope (also a misnomer), which is 25 cm in Submucosal anal cushion length or a flexible sigmoidoscope which is usually not available as an office procedure. Sigmoidoscopy may require a degree of Sphincter muscle preparation of the bowel by giving a disposable enema before the procedure if faecal loading precludes adequate vision. However, First degree haemorrhoid Dentate line information about faeces in the rectum, such as blood streaking, will be lost after bowel preparation. The doctor performing the Figure 2. Anatomy of the anal canal rigid sigmoidoscopy should be aware that the rectum is a curved Reprinted from AUSTraLIAN FAMILY PHYSICIAN VOL. 39, NO. 6, JUNE 2010 377 Anorectal pain, bleeding and lumps FOCUS Second degree haemorrhoids bleed during defecation and prolapse but reduce spontaneously after defecation. Rectal polyp Third degree haemorrhoids prolapse and may be painful if they are large. They have to be manually reduced. Second degree Internal sphincter First degree internal Fourth degree haemorrhoids are thrombosed internal piles internal haemorrhoid External sphincter haemorrhoid and present as permanently prolapsed and irreducible. They are Ischiorectal Third degree associated with mucous discharge and bleeding and are painful. Dentate line abscess (prolapsed) internal Perianal haemorrhoid abscess Ischiorectal Management fistula Treatment of haemorrhoids depends on the degree of prolapse and Anal fissure Perianal haematoma Prolapsed the extent of symptoms (Figure 4).3 All patients require conservative (fourth degree) haemorrhoid Perianal haematoma treatment. Those with second degree haemorrhoids, or more severe haemorrhoids, require additional measures such as sclerosant Figure 3. Classification of haemorrhoids injection, rubber band ligation or haemorrhoidectomy. The majority of first degree haemorrhoids can be managed by Insensitive anal mucosa Anorectal junction conservative measures alone. Treatment includes correction of Haemorrhoids Rectal mucosa constipation if present, by increasing the fibre intake, mild laxatives Rectum Haemorrhoids are common and are