– History –
- CC: most likely will present as perianal pain\abscess:
- Site: where? Does it radiate anywhere else?
- Onset: first time? When? Sudden\gradual? Intermittent\continuous? Better\worse?
- Character: dull, throbbing, stabbing?
- Aggravating\relieving: worse w\ defecation? Movement? Prolonged sitting?
- Severity: 1-10 scale? Wakes you up from sleep? Interfering w\ ADL?
- Associated sx:
- Constitutional: fever, chills, wt loss, decreased appetite?
- Perianal: swelling, itching, discharge (pus), bleeding (if yes, did you notice it on the toilet paper, underwear, mixed w\ stool, fresh\bright\dark, streak\spotting)?
- Stool: change in bowel habit (esp constipation), blood in stool?
- Urine: dysuria, blood in urine, straining?
- PMHx:
- Diseases:
- Chronic ds (HTN, DM, DLP)
- IBD
- Infections
- Medications
- Surgery, hospitalization, trauma
- Blood transfusions, IV drug use, tattoos
- Allergies
- Diseases:
- FMHx:
- Similar complaint?
- Same diseases as in PMHx?
- Social Hx:
- Occupation, marital status, children
- Smoking, alcohol, recreational drugs
- Travel Hx
- Diet, exercise (weight lifting)\
– Anorectal Physical Exam –
- WIPE, blah blah 🙂
- “Take vital signs”
- Position: Left lateral position, hips + knees flexed
- Proper exposure: from the waist to the knees
- Tell the pt it will be uncomfortable but not painful, and ask them to relax and take a deep breath
1. Inspection: (lift the uppermost buttock with your left hand)
- Skin: rashes, excoriation
- Scars, sinuses, fistulae openings
- Ulcers, fissures, skin tags
- Warts
- External hemorrhoids
- Abscesses:
- Fecal soiling, blood, mucus
- If you see and abscess, desribe it:
- By inspection:
- Site?
- Overlying skin: red, cellulitis, necrotizing fasciitis?
- Discharge?
- Sinus, fistula, punctum?
- By external palpation:
- Hot
- Tender
- Ill-defined
- Indurated
- Fluctuant
- Bulge on PR exam
- By inspection:
2. PR exam: (ask the pt if they have any pain?)
- Lubricate your finger
- Insert your finger and rotate 360°
- Assess sphincter tone:
- Ask pt to squeeze your finger
- Comment on:
- Irregular texture of the rectal wall?
- Masses?
- Stool in the rectum?
- Extra, depends on gender:
- If male -> palpate prostate;
- Normal prostate: “firm, rubbery, bi-lobed, symmetrical, 2-3 cm across, smooth surface, shallow central sulcus”
- If female -> do bimanual exam
- If male -> palpate prostate;
- Withdraw your finger + check glove for: blood, stool, mucous
3. To complete: examine inguinal LN
– Investigations –
- Usually no labs are needed, unless immunocompromised (DM, HIV) -> blood work (shows leukocytosis)
- Imaging might help if high clinical suspicion but not obviously apparent: CT, US, MRI
– Management –
- Incision and drainage
- Simple perianal abscess can be drain in ED, complex perirectal abscess can be drained in OR
- Abx are not indicated, unless SIRS\sepsis, cellulitis, DM, immunocompromised
– Complications –
- Fistula
- Bacteremia and sepsis
- Fecal incontinence