Anorectal disorders

A 43-year-old woman with no significant medical history comes to the physician with episodic rectal pain for the past 8 months. About once a month she has severe rectal pain that lasts for minutes and resolves without intervention. She has no fever, diarrhea, anal trauma, rectal bleeding, or weight loss. She has 1 formed bowel movement every 3 days without any straining and does not associate the pain with bowel movements. She takes no medications. Her blood pressure is 110/60 mm Hg, pulse is 76/min, and respirations are 14/min. Physical examination reveals a soft, nontender abdomen with normal bowel sounds. There is no hepatomegaly or splenomegaly. Rectal examination shows normal tone, no external hemorrhoids, and guaiac-negative brown stool. Pelvic examination is also unremarkable. Laboratory results are as follows: Hematocrit 38% Mean corpuscular volume 84 fL Platelets 280,000/μL Leukocytes 7,500/μL Colonoscopy is notable for small internal hemorrhoids and mild diverticulosis. Which of the following is the most likely cause of this patient's symptoms?

• Endometriosis

• Fibromyalgia

• Irritable bowel syndrome

• Proctalgia fugax

• Somatization disorder

A 32-year-old woman presents with severe anal pain that begins during defecation and continues for several hours afterward, described as sharp and throbbing. She has noticed bright red blood on the toilet paper. Inspection reveals a small tear in the posterior midline of the anal canal, and digital rectal examination is extremely painful. There are no fluctuating masses. Which of the following is the most likely diagnosis?

• Anal fissure

• Perianal abscess

• Pilonidal cyst

• Thrombosed external hemorrhoid

A 30-year-old man presents with a week of sharp anal pain that worsens with bowel movements and occasionally produces bright red blood on toilet paper. He has been taking warm sitz baths and using stool softeners without relief. He is otherwise healthy. Examination reveals a small tear at the posterior midline. What is the most appropriate next step in management?

• Topical diltiazem ointment

• Surgical lateral internal sphincterotomy

• Topical hydrocortisone cream

• Botulinum toxin injection into the anal sphincter

A 28-year-old woman comes to the physician because of bright red blood in her stools for 3 days. She has one bowel movement per day and no pain on defecation. She does not have a fever or abdominal pain. She was treated for a urinary tract infection with levofloxacin 3 months ago. Menses occur at regular intervals of 28-30 days and last 3-4 days. Her father died of colon cancer 4 years ago. Her only medication is an iron supplement. She is 162 cm (5 ft 4 in) tall and weighs 101.2 kg (223 lbs); BMI is 38 kg/m2. Her temperature is 36.5°C (97.7°F), pulse is 89/min, and blood pressure is 130/80 mm Hg. Rectal examination shows anal skin tags. Anoscopy shows multiple enlarged bluish veins above the dentate line at the 7 and 11 o'clock positions. During Valsalva maneuver, a rectal mass prolapses but spontaneously reduces when normal breathing is resumed. Which of the following is the most appropriate next step in management?

• Injection sclerotherapy

• Rubber band ligation

• Stool softeners

• Hemorrhoidectomy

A 41-year-old man comes to the physician because of a 3-day history of dull pain in the right buttock that worsens with defecation. He says that he cannot work at the office anymore because 'sitting down hurts.' During this time, he has not had any changes in stool frequency or appearance. He has hypothyroidism treated with levothyroxine. Temperature is 36.8°C (98.2°F), pulse is 70/min, respirations are 14/min, and blood pressure is 120/80 mm Hg. Physical examination shows a 3-cm erythematous, tender, fluctuant mass in the right perianal region with no exudate. Digital rectal examination elicits pain. Which of the following is the most appropriate initial step in management?

• Antibiotic therapy

• Sitz baths

• Rubber band ligation

• Incision and drainage

• Surgical resection

A 68-year-old man comes to the physician for a routine health maintenance examination. Over the past 6 months, he has had an increase in the frequency of bowel movements and occasional bloody stools. He has hypertension, coronary artery disease, and chronic obstructive pulmonary disease. His medications are aspirin, lisinopril, and salmeterol. He has smoked one pack of cigarettes daily for 40 years. His temperature is 37.0°C (98.6°F), pulse is 75/min, and blood pressure is 128/75 mm Hg. Cardiac examination shows no murmurs, rubs, or gallops. The lungs are clear to auscultation. The abdomen is soft with no organomegaly. Digital rectal examination shows a large internal hemorrhoid. Test of the stool for occult blood is positive. Which of the following is the most appropriate next step in management?

• Rubber band ligation

• Dietary counseling

• Colonoscopy

• Stool softeners

• Hemorrhoidectomy

A 40-year-old man presents with three months of intermittent purulent discharge from a small opening near his anus. He reports that a painful swelling in the anal area spontaneously ruptured a few weeks ago, followed by recurrent discharge. He denies rectal bleeding or constipation. On examination, there is a tiny opening lateral to the anal verge with a small amount of seropurulent fluid. Which of the following is the most likely diagnosis?

• External hemorrhoids

• Perianal fistula

• Pilonidal cyst

• Anal fissure

A 66-year-old woman, gravida 3, para 3, comes to the office because of a 1-month history of abdominal discomfort, difficulty completely emptying her bowel, and anal itching. She does not have pain with defecation and has not noticed any rectal bleeding. Upon straining, there is a soft, red mass measuring 6 cm in length protruding from the anus; concentric folds can be seen in the protruding tissue. Palpation of the mass does not cause pain. Digital rectal examination shows a reduced sphincter tone. Which of the following is the most appropriate treatment for this patient's condition?

• Rectopexy

• Pelvic muscle floor exercises

• Chemoradiation

• Cryotherapy

• Rubber band ligation

A 42-year-old man presents with sudden onset of severe anal pain after straining during a bowel movement. He reports that the pain worsens while sitting and improves with warm sitz baths. He has tried over-the-counter hemorrhoid creams with minimal relief. He denies fever, chills, or other systemic symptoms. Examination reveals a small, bluish, tender swelling at the anal verge, with a discrete lesion and no surrounding erythema or purulent discharge. Laboratory evaluations, including a complete blood count, are within normal limits. Which of the following is the most likely diagnosis?

• Anal fissure

• Perianal abscess

• Thrombosed external hemorrhoid

• Pilonidal cyst

A patient who presents with perianal pain is found to have multiple anal fissures, several of which are located lateral to the midline. In addition to treating symptoms, additional workup should be done to exclude which one of the following conditions?

• A. Crohn disease

• B. HIV infection

• C. Human papillomavirus infection.

• D. Proctalgia fugax