Internal Medicine

0521779407-B01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:52

226 Benign Disorders of the Rectum and Anus

■Incontinence: most common in women w/ sphincter injury after

vaginal delivery; less commonly associated w/ other injury, XRT,

prior anorectal surgery, neurologic disease

■Condyloma (HPV): associated w/ anorectal intercourse

Signs & Symptoms

■Hemorrhoids do not hurt unless acutely thrombosed; most com-

monly present w/ bleeding (blood on toilet paper, in toilet bowl);

rarely may cause anemia

■Fissure causes severe pain w/ or immediately after defecation; usu-

ally few symptoms apart from defecation; small amount of blood on

toilet paper or stool may occur; linear mucosal tear usually present

in posterior midline; if located at other parts of rectum, consider

Crohn disease, venereal disease

■Rectal prolapse: should be demonstrable during straining; pt may

not always be able to distinguish hemorrhoid prolapse from true

rectal prolapse

■Incontinence: associated w/ poor or absent sphincter pressure &/or

sensation; incontinence w/o sensation differs from rectal urgency

w/ loss of control

tests

Laboratory

■Unimportant except rarely anemia from bleeding hemorrhoids

■Incontinence may require cinedefecography, nerve conduction

studies

■Pathology on condyloma important to exclude malignancy

Imaging

■Cinedefecography may be helpful for incontinence

■If fissure unusual in appearance or location, consider imaging

remainder of GI tract to look for Crohn disease

differential diagnosis

■All pts w/ bleeding per rectum or guiaic positive (can occur w/ hem-

orrhoids, fissure, prolapse) should undergo colonoscopy

■Most fissures benign, but consider Crohn disease, venereal disease,

trauma if appearance or location of fissure unusual

■Cause of incontinence usually apparent from history & physical

exam

■Consider associated squamous cell carcinoma in pts w/ condyloma