Anorectal disorders

DDX

1. Anal Tags
2. Hemorrhoids
3. Cryptitis
4. Anal Fissure
5. Anal Fistula
6. Anorectal Abscess
7. Proctitis
8. Rectal Prolapse
9. Rectal Foreign Body
10. Pruritus Ani
11. Pilonidal Cyst

Algorithmic Approach

Pain and Bleeding

1. External hemorrhoid
2. Prolapsed internal hemorrhoid
3. Anal fissure
   1. Off midline = cancer, HIV, TB, Crohn's

Pain, No Bleeding

1. Swelling
   1. Abscess
      1. Perirectal
      2. Ischiorectal
      3. Intersphincteric
      4. Supralevator
   2. Pilonidal (drain off midline)
   3. Fistula (2/2 chronic abscess; don't probe)
   4. Hidradenitis suppurativa
2. No swelling
   1. Proctalgia fugax
      1. Cramp of pubococcygeus or levator ani muscles
      2. Episodic pain (women, pts < 45yo)
      3. Incontinence
      4. Urgency

Bleeding, No Pain

1. Cancer
2. Internal hemorrhoid

Painless Swelling

1. Itch: Condyloma acuminata (warts 2/2 HPV)
2. No itch: Rectal prolapse

Itching

1. Discharge: Proctitis
2. No discharge: Pruritis ani

Source

Donaldson; adapted from Coates