Perianal symptoms

Anal and Perianal Skin Conditions

Hemorrhoids: Painless bright red rectal bleeding, pruritus, and discomfort, especially after defecation.
Anal fissure: Severe pain during and after defecation, with possible bright red bleeding; often associated with constipation.
Perianal abscess: Severe perianal pain, swelling, redness, and fever; may progress to a fistula.
Anal fistula: Chronic drainage of pus or stool from an opening near the anus; often following an abscess.
Perianal dermatitis: Pruritus, erythema, and irritation of the perianal skin; may be caused by moisture, friction, or infections.
Condylomata acuminata (anal warts): Caused by HPV; presents as painless, cauliflower-like growths in the perianal region.
Anal cancer: Persistent anal pain, bleeding, and a mass or ulceration; associated with HPV infection.
Pruritus ani: Itching around the anus, often idiopathic, but may be related to dermatological conditions, infections, or hemorrhoids.

Gastrointestinal Causes

Inflammatory bowel disease (Crohn’s disease and ulcerative colitis): Chronic diarrhea, rectal bleeding, and perianal pain; may present with perianal fistulas or abscesses.
Proctitis: Inflammation of the rectum causing rectal pain, bleeding, and tenesmus; may be associated with STIs or IBD.
Colorectal cancer: May present with rectal bleeding, change in bowel habits, weight loss, and perianal discomfort or mass.
Diverticulitis: Lower abdominal pain, fever, and change in bowel habits; may lead to perianal fistula formation in chronic cases.
Anal stenosis: Narrowing of the anal canal causing pain during defecation, straining, and thin stools.
Rectal prolapse: Protrusion of rectal tissue through the anus, causing discomfort, bleeding, and incontinence.

Infectious Causes

Sexually transmitted infections (e.g., gonorrhea, chlamydia, syphilis, herpes): May present with perianal pain, discharge, ulcers, or warts.
Perianal streptococcal infection: Common in children; presents with perianal redness, pain, and itching.
Fungal infections (e.g., candidiasis): Pruritus, erythema, and a rash in the perianal region, especially in immunocompromised patients.
Enterobiasis (pinworms): Nocturnal perianal itching caused by Enterobius vermicularis infection, often in children.
Tuberculosis: Rarely, can cause perianal fistulas or ulcers, especially in immunocompromised individuals.
HIV/AIDS: Can lead to various perianal manifestations, including infections, warts, and malignancies.

Onset and Duration

Acute onset: Suggests conditions such as perianal abscess, anal fissure, or acute hemorrhoidal thrombosis.
Chronic or recurrent symptoms: More consistent with conditions like hemorrhoids, IBD, or anal fistulas.
Intermittent symptoms: May suggest conditions like pruritus ani, hemorrhoids, or chronic fissures.

Character of Symptoms

Pain: Severe pain during defecation suggests anal fissure; constant pain with fever may indicate abscess.
Itching: Common in pruritus ani, dermatitis, or fungal infections.
Bleeding: Bright red bleeding with defecation is often due to hemorrhoids or fissure; darker blood or mixed with stool suggests more proximal causes.
Discharge: Pus or stool discharge suggests a fistula; clear or mucoid discharge may be seen in proctitis or STIs.
Mass: A palpable mass or lump could indicate hemorrhoids, anal cancer, or a thrombosed external hemorrhoid.
Ulceration: Painful ulcers are commonly due to herpes or syphilis; chronic ulcers raise concern for malignancy or IBD.
Changes in bowel habits: Diarrhea, constipation, or tenesmus could indicate IBD, colorectal cancer, or infectious proctitis.

Background

Past medical history: Includes history of IBD, previous perianal surgery, or conditions like diabetes that predispose to infections.
Medication history: Review use of immunosuppressants, antibiotics, or medications that may cause constipation or diarrhea.
Family history: Consider familial patterns of IBD, colorectal cancer, or dermatological conditions.
Sexual history: Important for assessing risk of STIs, especially in cases of proctitis or unexplained perianal symptoms.
Social history: Includes smoking, alcohol use, and occupational factors that may influence bowel habits or hygiene practices.
Dietary habits: High-fat, low-fiber diet may contribute to constipation, hemorrhoids, or fissures.
Recent travel: Consider exposure to infections or parasites, particularly in endemic areas.

Physical Examination

Digital rectal examination (DRE): Assesses for masses, tenderness, sphincter tone, and presence of blood.
Proctoscopy: Allows direct visualization of the anal canal and lower rectum; useful for diagnosing hemorrhoids, fissures, and masses.
Anoscopy: More detailed examination of the anal canal, particularly useful for hemorrhoids, fissures, and warts.
Examination under anesthesia (EUA): Performed when thorough examination is required, such as in abscesses or complex fistulas.
Skin examination: To assess for dermatitis, fungal infections, or other dermatological conditions.
Abdominal examination: To check for masses, tenderness, or organomegaly that may suggest gastrointestinal causes.

Laboratory Tests

Full blood count (FBC): To identify anemia, infection, or inflammation.
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR): Elevated in cases of infection or inflammation, such as IBD or abscess.
Stool studies: To check for infection, parasites, or occult blood.
Sexually transmitted infection (STI) screening: Important in cases of suspected proctitis or other sexually transmitted infections.
Glucose levels: To assess for diabetes, which predisposes to infections like perianal abscess.
Biopsy: Indicated if there is suspicion of malignancy, chronic ulcers, or unexplained perianal lesions.
HIV test: Consider in cases of persistent perianal symptoms, particularly with a history of high-risk behavior.

Imaging

Pelvic MRI: Useful for complex fistulas, abscesses, or suspected malignancies.
Endoanal ultrasound: Useful in assessing sphincter integrity and diagnosing perianal abscesses or fistulas.
CT scan: Considered if there is suspicion of complications such as abscess formation or malignancy.
Barium enema: Occasionally used to assess for colorectal pathology in cases of chronic symptoms or when colonoscopy is not feasible.
Colonoscopy: Indicated in cases where there is a concern for IBD, colorectal cancer, or unexplained rectal bleeding.
Sigmoidoscopy: Allows for visualization of the rectum and lower colon; useful in diagnosing IBD, proctitis, or neoplasms.

Gastrointestinal