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 

References:

1) Cohee MW, Hurff A, Gazewood JD. Benign Anorectal Conditions: Evaluation and Management. Am Fam Physician. 2020 Jan 1;101(1):24-33.

2) Foxx-Orenstein AE, Umar SB, Crowell MD. Common anorectal disorders. Gastroenterol Hepatol (NY). 2014;10(5):294-301. 

3) Gracia Solanas JA, Ramírez Rodríguez JM, Elía Guedea M, Aguilella Diago V, Martínez Díez M. Sequential treatment for proctalgia fugax. Mid-term follow-up. Rev Esp Enferm Dig. 2005 Jul;97(7):491-6. English, Spanish. doi: 10.4321/s1130-01082005000700004. PMID: 16262528.