Anal canal / Clinical

TAKING HISTORY FROM A PATIENT WITH Anal condition

Follow the general scheme (on this page)  and use the following set of symptoms in the part of “Other symptoms in Relation to the main complaint

  • Swelling
  • Pain
  • Discharge
  • Bleeding
  • Pruritus
  • Change bowel habits
  • Incontinence

Examination

Position
  • Left lateral position
  • Chin rest on the chest
  • Hip flexed 90o or more 
  • Knee flexed less than 90o
Inspection
  • Skin rash and excoriation
  • Faecal soiling, blood or mucus
  • Scaring, or opening of a fistula
  • Lumps and bumps
  • Ulcers, especially fissures
Palpation (digital rectal examination “DRE”)
  • Inspect your finger, when you remove it
  • The Anal canal
    • Tone of the sphincter
    • Pain or tenderness
    • Thickening or masses
  • The rectum
    • Texture of the wall of the rectum
    • Masses
      • Mobility of the mucosa over the mass to decide if it is within or outside the wall
    • Ulcers
    • Content of the rectum
      • Hard or soft
      • Faeces may feel like a tumor but are indentable
  • The recto-vesical/recto-uterine pouch
  • Bimanual examination
  • The cervix and uterus
  • The prostate and seminal vesicles
Proctoscopy
Sigmoidoscopy

Differential diagnosis of different anal disorders and approach for diagnosis

Diagnosis of conditions which present with rectal bleeding
Bleeding but no pain
Blood mixed with stool Carcinoma of colon Also proctitis caused by specific infection (e.g. schistosomiasis)
Blood streaks on stool Carcinoma of the rectum
Blood after defecation Heamorrhoids
Blood and mucus Colitis
Blood alone Diverticular disease
Melena Peptic ulceration
Bleeding + pain
  • Fissure
  • Carcinoma of anal canal
Diagnosis of conditions which present with pain
Pain
  • Fissure (pain after defecation)
  • Proctalgia fugax (pain spontaneously at night)
  • Anorectal abscess
Pain and bleeding
  • Fissure
Pain and lump
  • Perianal haematoma
  • Anorectal abscess
Pain, lump and bleeding
  • Prolapsed haemorrhoids
  • Carcinoma of the anal canal
  • Prolapsed rectal polyp or carcinoma
  • Prolapsed rectum
Diagnosis of conditions which present with lump
Lump and no other symptoms
  • Anal warts
  • Skin tags
Lump and pain
  • Peri-anal haematoma
Lump, pain and bleeding
  • Prolapsed haemorrhoids
  • Carcinoma of the anal canal
  • Prolapsed rectal polyp or carcinoma
  • Prolapsed rectum
Common causes of acute anal pain
  • Fissure in ano
  • Anal abscess
  • Strangulated pile
  • Perianal heamatoma
  • Proptalgia fugax
The causes of Pruritus ani
Mucus discharge from the anus
  • Haemorrhoids
  • Polyps
  • Skin tages
  • Condylomata
  • Fissure
  • Fistula
  • Carcinoma of the anus
Vaginal discharge
  • Tricomonas vaginitis
  • Monilia vaginitis
  • Cervicitis
  • Gonorrhea
Skin disease
  • Tinea cruris
  • Fugal infections, especially monilial
  • Infection in diabetics
Parasites
  • Threadworm
Faecal soiling
  • Poor hygiene
  • Incontinence
  • Diarrhea
Psychoneurosis
Differences between acute anal fissure and chronic anal fissure

Acute anal fissure

Chronic anal fissure

Soft Indurated
Spastic muscle Fibrotic muscle
Conservative treatment Operative treatment

Cardinal symptoms of common anal disorders

Anal disorders usually share the same symptoms but every disorder has its own cardinal symptom

Disease

Cardinal symptom

Other symptoms

Fissure Pain Sentinel pile (swelling)
Abscess Swelling Continuous throbbing painful swelling
Fistula Discharge Pruritus
Haemorrhoids Bleeding Pruritus