Duncan ill with very bad piles—operated on last night, or, since that sounds alarming, lanced. Can’t really sympathise with that particular disease, though the pain is terrible. Must laugh.
VIRGINIA WOOLF 1934, DIARY ENTRY
Anorectal problems are common in family practice and tend to cause anxiety in the patient that is often related to the fear of cancer. This fear may be well founded for many instances of rectal bleeding and lumps. It is important to keep in mind the association between haemorrhoids and large bowel cancer.
Anorectal problems include:
Common anorectal conditions are illustrated in FIGURE 36.1.
Common anorectal conditions
ANORECTAL PAIN (PROCTALGIA)
The patient may complain that defecation is painful or almost impossible because of anorectal pain.
solitary rectal ulcer
strangulated internal haemorrhoids
abscess: perianal, ischiorectal
Anal fissures cause pain on defecation and usually develop after a period of constipation (may be a brief period) and tenesmus. Other associations are childbirth and opioid analgesics.1 Sometimes the pain can be excruciating, persisting for hours and radiating down the back of both legs. Anal fissures, especially if chronic, can cause minor anorectal bleeding (bright blood) noted as spotting on the toilet paper.
On inspection the anal fissure is usually seen in the anal margin, situated in the midline posteriorly (6 o’clock)—90% of fissures. The fissure appears as an elliptical ulcer involving the lower third of the anus from the dentate line to the anal verge (see FIG. 36.2).1
Anal fissure with prominent skin tag situated in the mid posterior position of the anal verge: the 6 o’clock position
Digital examination and sigmoidoscopy are difficult because of painful anal sphincter spasm. If there are multiple fissures, Crohn disease should be suspected. These fissures look different, being indurated, oedematous and bluish in colour.
In chronic anal fissures a sentinel pile is common and in long-standing cases, a subcutaneous fistula is seen at the anal margin, with fibrosis and anal stenosis.1
Red flag pointers for anorectal pain
The aim is to disrupt the cycle of anal sphincter spasm, ...